West Reading Skilled Nursing And Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in West Reading, Pennsylvania.
- Location
- 425 Buttonwood Street, West Reading, Pennsylvania 19611
- CMS Provider Number
- 395351
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at West Reading Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with muscle wasting, dysphagia, protein-calorie malnutrition, traumatic brain injury, and significant cognitive impairment required staff assistance with eating, including small bites, verbal cues for frequent drinks, and checks for food remaining in the mouth. During a lunch meal, an LPN was observed standing while assisting the resident with eating, contrary to the resident’s care needs and facility expectations. The DON later confirmed that staff are not to stand when feeding residents, demonstrating a failure to provide dining assistance in a manner that maintains resident dignity.
The facility failed to ensure accurate completion of MDS assessments for three residents, resulting in discrepancies between documented treatments/medications and the clinical record. One resident receiving oxygen therapy was incorrectly coded on the MDS as not having received oxygen in the prior seven days. Two other residents, one with hepatic failure and asthma and another with cerebrovascular disease and bipolar disorder, were both coded on their MDS assessments as receiving anticoagulant medications, despite no corresponding physician orders for anticoagulants in their clinical records. The DON confirmed at least one of these MDS assessments was inaccurate.
Staff failed to follow physician-ordered blood pressure parameters for midodrine administration for two residents. One resident with hypertension and renal dialysis received midodrine multiple times when SBP was documented above the ordered cutoff of 130 mm/Hg. Another resident with hypotension, chronic respiratory failure, and peripheral vascular disease received midodrine numerous times over several months when SBP exceeded the ordered limit of 120 mm/Hg. The DON confirmed that midodrine was administered outside the prescribed parameters for both residents.
A resident with a history of stroke, dysphagia, significant cognitive impairment, and a gastrostomy tube had a care plan and posted signage requiring Enhanced Barrier Precautions (EBP), including gown use, during high-contact direct care such as hygiene and feeding tube care. Despite this, an LPN was observed providing feeding tube care while sitting on the resident’s bed without a gown, and the LPN and a nurse aide then provided hygiene care to the resident without gowns. The DON later confirmed that gowns should have been worn during this care, indicating staff did not follow the facility’s EBP policy or the resident’s care plan.
A resident’s bedside call light was found to be nonfunctional when activated, as it did not illuminate or sound at the nurse’s station despite facility policy requiring an operable call system at each bedside, toilet, and bathing room. A NA confirmed the call light cord was damaged and needed replacement, and the Administrator acknowledged that the facility failed to maintain a fully functioning call bell system in that room.
A review of nursing schedules revealed that the facility did not meet the required minimum NA-to-resident ratios on multiple evening and overnight shifts during a 21-day period. The deficiency was identified through an examination of staffing records, which showed insufficient NA coverage on five separate shifts.
A review of nursing schedules showed that the facility did not meet required LPN-to-resident ratios on multiple occasions, with insufficient LPN coverage during day, evening, and night shifts over an observed period.
A review of nursing schedules showed that, on five days within a 21-day period, the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident. On these days, the care hours ranged from 2.91 to 3.11 per resident, falling short of regulatory standards.
Multiple residents did not consistently receive showers or hygiene assistance according to their preferences, with documentation and interviews revealing missed care occasions. Residents and staff reported that cold water in shower and resident rooms led to refusals and made it difficult to provide dignified ADL care. Facility leadership acknowledged ongoing water temperature issues that contributed to the inconsistent provision of showers and hygiene.
The facility failed to maintain clear exit access corridors on multiple floors, with obstructions such as side chairs, linen carts, bed tables, and large containers found during observations. These issues were confirmed by maintenance staff and remained uncorrected during a follow-up visit.
The facility did not adhere to NFPA 101 standards for soiled linen and trash container capacity, as observed on the 3rd floor Central Bath near a resident room. Containers exceeded the 32-gallon limit in a 64-square foot area, confirmed by maintenance staff. A follow-up observation showed the issue remained uncorrected.
West Reading Skilled Nursing and Rehabilitation Center failed to comply with regulations for labeling and storing medications. Insulin pens on a medication cart were not discarded after 28 days, and expired Prevnar 20 syringes were found in the third-floor medication storage room. An LPN and the DON confirmed the facility's policy was not followed.
The facility did not meet the required LPN to resident ratio on one of the reviewed days. On a specific day during the day shift, the facility failed to provide the mandated minimum of one LPN per 25 residents, as identified through a review of nursing schedules.
The facility failed to maintain clear and unobstructed exit access corridors on three of its four floors. Observations revealed various items, including side chairs, linen carts, bed tables, and containers, stored in the corridors on the 2nd, 3rd, and 4th floors. The Director of Maintenance confirmed the issue.
The facility did not maintain stairtower doors according to NFPA 101 standards. The 4th floor 2D stairtower door had excessive gaps, and the 1D stairtower door had broken panic hardware and was improperly secured, preventing it from opening. These issues were confirmed by the Director of Maintenance.
The facility failed to comply with NFPA 101 standards by allowing accumulated trash and soiled-linen containers to reach 32 gallons in a 64-square foot area on the 3rd floor Central Bath, near a resident room. This was outside a protected area, violating the requirement for such containers to be within a protected hazardous area if exceeding the specified capacity. The Director of Maintenance confirmed the oversight.
The facility did not perform the required semi-annual testing of the kitchen suppression system, as it was only inspected once in the year. This was confirmed by the Director of Maintenance during an interview.
The facility failed to store food in a sanitary manner, with multiple undated food items found in coolers and dry storage, and inadequate chemical levels in the dish machine. Additionally, the resident pantry on Nursing Unit 2 contained unlabeled and undated food items. Interviews confirmed the lack of proper labeling and documentation of tray line temperatures.
The facility did not employ a full-time qualified dietary services manager in the absence of a full-time dietitian. Interviews with the dietary manager and Administrator confirmed the absence of both a certified dietary manager and a full-time dietitian.
The facility did not follow pre-approved menus, as residents reported frequent meal substitutions without notice. Observations confirmed that on two occasions, the meals served did not match the planned menu items. The Dietary Manager acknowledged the discrepancies.
The facility failed to develop comprehensive care plans for four residents, neglecting to address specific medical conditions such as pressure ulcers, indwelling catheters, pain management, and urinary incontinence, as identified in the MDS CAA summaries. The DON confirmed these omissions.
The facility failed to follow physician's orders for two residents. A resident with hypotension received medication outside the prescribed blood pressure parameters, while another resident with multiple diagnoses was not weighed as ordered. The DON confirmed these deficiencies.
A resident with cognitive impairment and mobility issues experienced multiple unwitnessed falls without additional safety interventions being implemented. The facility failed to conduct a bowel and bladder assessment and safety checks as planned, and did not notify the physician of a fall, as confirmed by the DON.
The facility did not ensure timely action on pharmacy recommendations for two residents. A resident with Parkinsonism, dementia, and depression had multiple pharmacy recommendations from June to November 2024, with no documentation or physician action noted. Another resident with syncope, hypertension, and dementia had recommendations in September and November 2024, also lacking documentation or physician response. The DON confirmed the absence of documentation or timely action.
The facility failed to properly store medications in the Second Floor Nursing Unit. Observations revealed several insulin pens and a vial of Tubersol were opened and not labeled with open dates. Additionally, expired medications were found in the storage room. An LPN and the DON confirmed the requirement to label medications and remove expired ones.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers due to changes in medical conditions. Eight residents were affected, and the facility's administrator confirmed the lack of required notices.
The facility did not post accurate and current nurse staffing information. During a tour, it was observed that the staffing data in the lobby was outdated. The Administrator confirmed the error in an interview.
The facility was found to have improperly disposed of trash and refuse. Observations revealed multiple pieces of crushed plastic, cardboard debris, crushed Styrofoam containers, and used gloves around the dumpsters. One dumpster had a lid wide open and another lid with two full bags of garbage on top.
The facility did not meet the required nurse aide (NA) to resident ratios on several occasions, failing to provide one NA per ten residents during the day and one NA per eleven residents in the evening. This deficiency was observed over multiple days in September, October, and December 2024, as revealed by a review of nursing schedules.
The facility failed to meet the required NA to resident ratio during the night shift on specific dates in September and December 2024. Additionally, the facility did not comply with the minimum LPN to resident ratios on several occasions, including during the day shift in October and the evening and night shifts in December and September 2024. These deficiencies were identified through a review of nursing time schedules over a 21-day period.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on eight occasions, with the lowest being 2.63 hours. This shortfall was identified over a 21-day review period, indicating a consistent failure to provide adequate staffing levels.
A facility failed to notify a resident's responsible party of a significant change in treatment, as required by policy. The resident, with respiratory and cognitive conditions, was prescribed azithromycin due to unresolved symptoms. However, there was no evidence of notification to the responsible party, confirmed by the DON.
The facility failed to store food properly in the dietary department and on three nursing units. Observations revealed multiple food items without proper labeling or dating, contrary to facility policy. Dietary Employee 1 and a nurse confirmed the requirement for labeling and dating, which was not followed.
Failure to Maintain Dignity During Assisted Dining
Penalty
Summary
Surveyors identified that the facility failed to provide dining assistance in a manner that promoted and maintained dignity for one resident. The resident had diagnoses including muscle wasting, dysphagia, protein-calorie malnutrition, and a history of traumatic brain injury, and a recent MDS assessment documented significant cognitive impairment with a need for staff assistance with eating. The resident’s care plan directed staff to assist with meals as needed, encourage small bites, provide verbal cues to take frequent drinks, and check for food remaining in the mouth after swallowing. During an observation of a lunch meal, an LPN was seen standing while assisting the resident with eating from 12:25 p.m. to 12:40 p.m. In a subsequent interview, the Director of Nursing stated that staff should not stand when feeding residents, confirming that the observed feeding practice did not align with expectations for maintaining resident dignity.
Inaccurate MDS Assessments for Treatments and Medications
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the current clinical status and treatments for three sampled residents. For one resident who began receiving oxygen therapy on September 25, 2025, the MDS assessment dated [DATE] documented in Section O that the resident had not received oxygen therapy in the preceding seven days, despite clinical records confirming ongoing oxygen use; the DON later confirmed this MDS was inaccurate. For another resident with hepatic failure and asthma, the MDS dated [DATE] indicated the resident was receiving an anticoagulant medication, but review of the clinical record revealed no physician orders for any anticoagulant. Similarly, for a resident with cerebrovascular disease and bipolar disorder, the MDS dated [DATE] also indicated receipt of an anticoagulant medication, yet the clinical record contained no corresponding physician orders. These discrepancies between the MDS assessments and the clinical records demonstrate that the assessments did not accurately capture the residents’ actual treatments and medication regimens.
Failure to Follow Midodrine Blood Pressure Parameters for Two Residents
Penalty
Summary
The facility failed to follow physician orders for administration of the blood pressure medication midodrine for two residents. For one resident with hypertension and renal dialysis, a physician ordered midodrine to be given three times a day on certain days of the week and twice a day on the remaining days, with a specific parameter that the medication was not to be administered if the resident’s systolic blood pressure (SBP) was greater than 130 mm/Hg. Review of this resident’s Medication Administration Records (MARs) for December 2025 and January 2026 showed that staff administered midodrine three times in December and four times in January when the resident’s SBP exceeded 130 mm/Hg, contrary to the physician’s order. For another resident with hypotension, chronic respiratory failure, and peripheral vascular disease, a physician ordered midodrine three times a day with the instruction that it was not to be administered if the SBP was greater than 120 mm/Hg. Review of this resident’s MARs for October, November, and December 2025, and January 2026 revealed that staff administered midodrine 28 times in October, 39 times in November, 26 times in December, and two times in January when the SBP was greater than 120 mm/Hg, again outside the ordered parameters. In an interview, the Director of Nursing confirmed that the medications for both residents were administered outside the parameters ordered by the physicians.
Failure to Follow Enhanced Barrier Precautions for Resident With Feeding Tube
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling medical device. The facility’s EBP policy, last reviewed November 14, 2025, required the use of protective gowns during high-risk activities for any resident with an indwelling medical device when contact was expected, and staff were to be trained on what constituted high-risk activity. Resident 113 had diagnoses including stroke and dysphagia and had a gastrostomy tube in place. The Minimum Data Set dated November 3, 2025, documented significant cognitive impairment and the presence of a feeding tube. The resident’s care plan directed staff to follow EBP when providing personal care and when handling the feeding tube, and a sign posted outside the resident’s room instructed staff to use EBP, including gowns, during high-contact direct care such as hygiene and feeding tube device care. On January 27, 2026, at 10:30 a.m., an LPN was observed sitting on Resident 113’s bed without wearing a protective gown while providing care to the resident’s feeding tube, despite the posted EBP sign. From 10:31 a.m. to 10:41 a.m. that same day, the same LPN and a nurse aide provided hygiene care to Resident 113 without wearing gowns. The nurse aide later confirmed in an interview that hygiene care was being provided during that time. In a subsequent interview on January 29, 2026, the Director of Nursing stated that staff should have worn gowns when providing care to Resident 113, confirming that the observed practice did not comply with the facility’s EBP policy and the resident’s care plan.
Nonfunctioning Call Light at Bedside
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system for one sampled resident when the call light at the resident’s bedside did not operate as required. Facility policy titled “NSG Call Lights,” dated November 15, 2025, stated that patients will have a call light or alternative communication device at each patient’s bedside, toilet, and bathing room to allow patients to call for assistance when unattended. On January 27, 2026, at 11:27 a.m., observation showed that pressing the button on the call light cord at the resident’s bed did not cause the light to illuminate or the signal to sound at the nurse’s station. At 11:45 a.m., NA 1 confirmed that the call light cord was damaged and required replacement. On January 28, 2026, at 1:30 p.m., the Administrator confirmed that the facility failed to maintain a fully functioning resident call bell system in one room. No additional medical history or clinical condition for the resident was provided in the report.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
A review of nursing schedules for a 21-day period from July 5 to July 25, 2025, showed that the facility did not meet the required minimum nurse aide (NA) to resident ratios on five separate days. Specifically, on two evening shifts, the facility failed to provide at least one NA for every 11 residents, and on three overnight shifts, the facility did not meet the minimum of one NA for every 15 residents. These findings were based solely on the documented nursing time schedules reviewed for the specified period. No additional information regarding the residents' medical history, conditions, or specific incidents involving patient care was provided in the report.
Plan Of Correction
1&2. Nurse Scheduler re-educated on the NA ratio requirements of 1 NA to 10 residents on day shift, 1 NA to 11 residents on evening shift, and 1 NA to 15 residents on night shift. 3. The facility is actively recruiting NAs; utilizing Nurse Agency to supplement NAs; and Mon-Fri staffing meetings conducted in attempts to maintain State Mandated ratios for NAs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of NAs are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to comply with state regulations requiring minimum licensed practical nurse (LPN) to resident ratios during specified shifts. A review of nursing schedules for a 21-day period revealed that on eight separate days, the facility did not meet the mandated LPN staffing levels. Specifically, the day shift on one day did not have the required one LPN per 25 residents, the evening shift on two days did not meet the one LPN per 30 residents ratio, and the night shift on six days failed to provide one LPN per 40 residents. These findings were based solely on the review of the facility's nursing time schedules for the period in question. No additional information regarding the residents' medical history, conditions, or specific outcomes related to the staffing deficiencies was provided in the report.
Plan Of Correction
1&2. Nurse Scheduler re-educated on the LPN ratio requirements of 1 LPN to 25 residents on day shift, 1 LPN to 30 residents on evening shift, and 1 LPN to 40 residents on night shift. 3. The facility is actively recruiting LPNs; utilizing Nurse Agency to supplement LPNs; and Mon-Fri staffing meetings conducted in attempts to maintain State Mandated ratios for LPNs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of LPNs are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules for a 21-day period revealed that on five specific days, the total nursing care hours fell below the mandated minimum. The recorded care hours per resident on these days ranged from 2.91 to 3.11, which did not satisfy the required threshold. This deficiency was identified through the examination of documented nursing time schedules and was not linked to any specific residents' medical histories or conditions.
Plan Of Correction
1 & 2. Nurse Scheduler re-educated on the PPD requirements of 3.2 hours of direct care for each resident. 3. The facility is actively recruiting Nursing staff; utilizing Nurse Agency to supplement Nursing Staff; and Mon-Fri staffing meetings conducted in attempts to maintain State Mandated PPD of 3.2 hours of direct care for each resident. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of Nursing Staff are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Failure to Maintain Resident Dignity and Preferences in Hygiene Care
Penalty
Summary
The facility failed to provide care and services in a manner that maintained the dignity and preferences of four residents, as evidenced by inconsistent assistance with showers and personal hygiene. Clinical record reviews and interviews revealed that residents with varying diagnoses, including major depressive disorder, stroke with hemiplegia, diabetes, and adjustment disorder, did not consistently receive showers according to their preferred schedules. Documentation showed multiple occasions where there was no evidence that showers or hygiene assistance were provided as planned. Residents reported that the water in the shower rooms and resident rooms was often cold, leading to refusals of showers and dissatisfaction with personal care. Some residents stated that staff did not offer alternatives, such as using a different shower room with warmer water. One resident expressed that his hair had grown too long and no one had offered to cut it or schedule a haircut, while another was observed with facial hair despite preferring to be clean-shaven. Nursing staff confirmed that cold water in the shower and resident rooms made it difficult to complete activities of daily living (ADL) care in a dignified manner. Facility leadership acknowledged ongoing water temperature issues on a specific nursing unit, which contributed to the inability to provide showers and hygiene as preferred by the residents. These findings were supported by clinical documentation, resident and staff interviews, and direct observation.
Obstructed Exit Access Corridors
Penalty
Summary
The facility failed to maintain clear and unobstructed exit access corridors on three of four floors, as required by NFPA 101 Means of Egress standards. During an observation on December 11, 2024, between 12:30 PM and 1:30 PM, various items were found stored in the egress corridors. On the 4th floor, side chairs, linen carts, and bed tables were obstructing the corridor. On the 3rd floor, similar items along with a shredder container were found outside the Lounge/Dining Room. On the 2nd floor, two containers, each greater than 32 gallons, were located at the smoke doors by the Central Bath. An interview with the Director of Maintenance confirmed these findings. A follow-up observation on February 7, 2025, revealed that the obstructions on the 3rd floor and the containers on the 2nd floor had not been corrected, as confirmed by an interview with a maintenance staff member.
Plan Of Correction
Various items such as chairs, linen carts, bed tables, containers greater than 32 gallons, and the shredder container were removed from floors 2, 3, and 4 and placed in appropriate locations. The Maintenance Director or Designee will re-educate employees on the expectation of keeping areas of exit free of all obstructions such as chairs, linen carts, bed tables, containers greater than 32 gallons, and the shredder container to full use in case of emergency. The Maintenance Director or Designee & DON or Designee will do random monthly audits of all floors to ensure aisles, passageways, corridors, and exits are free of all obstructions. The Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Non-compliance with Soiled Linen and Trash Container Capacity
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the capacity of soiled linen and trash containers. On December 11, 2024, an observation revealed that the accumulated trash and soiled-linen containers exceeded the allowed 32 gallons in a 64-square foot area in the 3rd floor Central Bath, near Resident Room 307. This was confirmed through an interview with the Director of Maintenance. A follow-up observation on February 7, 2025, confirmed that the issue had not been corrected, as verified by an interview with Maintenance Man 1.
Plan Of Correction
Maintenance removed all observed accumulated trash and soiled linen containers in the 3rd floor central bath by resident room 307. Maintenance Director or Designee will re-educate employees on the importance of not placing containers greater than 32 gallons in a 64-square foot area. Maintenance Director or Designee & DON or Designee will complete weekly random audits of the bath areas to ensure there are no trash or soiled linen containers in this area. Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Non-compliance in Medication Storage and Labeling
Penalty
Summary
West Reading Skilled Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the labeling and storage of drugs and biologicals. The facility's policy required staff to label insulin vials and pens with the date they were first opened and to dispose of outdated, contaminated, discontinued, or deteriorated medications immediately. However, during a survey, it was observed that insulin pens on a medication cart for resident rooms 218 through 229 were not discarded after the recommended 28 days. Specifically, an insulin aspart pen opened on December 16, 2024, an insulin glargine pen opened on December 11, 2024, and a Semglee insulin pen opened on December 12, 2024, were still present. A licensed practical nurse confirmed that these pens should have been discarded. Additionally, the survey revealed that the medication storage room refrigerator on the third floor contained six single-dose pre-filled syringes of Prevnar 20 with an expiration date of December 2024. The Director of Nursing acknowledged that staff were responsible for labeling all medications with open and expiration dates and ensuring that expired or discontinued medications were removed from storage. These findings indicate a failure to adhere to the facility's medication storage policy, leading to the presence of expired medications in the facility.
Plan Of Correction
Insulin pens in the 2nd floor medication cart have been discarded. Expired Prevnar solution in 3rd floor medication refrigerator has been discarded. Medication carts have been inspected to ensure Insulin pens are labeled/dated and are current. Medication refrigerators have been inspected to ensure expired medications are discarded. Licensed nursing staff have been re-educated on F761 and the medication storage policy with attention to storage of insulin pens and discarding expired medications. DON/designee will audit medication carts and refrigerators at least weekly x4weeks then monthly x2months to ensure expired medications are discarded. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Failure to Meet LPN to Resident Ratio
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one of the four days reviewed. Specifically, on January 25, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated minimum of one LPN per 25 residents. This deficiency was identified through a review of the nursing schedules for the period from January 23 to January 26, 2025.
Plan Of Correction
1 & 2. Nurse Scheduler re-educated on the LPN ratio requirements of 1 LPN to 25 residents on day shift, 1 LPN to 30 residents on evening shift, and 1 LPN to 40 residents on night shift. 3. The facility is actively recruiting LPNs; utilizing Nurse Agency to supplement LPNs; and Mon-Fri staffing meetings conducted in attempts to maintain State Mandated ratios for LPNs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of LPNs are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Obstructed Exit Access Corridors
Penalty
Summary
The facility failed to maintain clear and unobstructed exit access corridors on three of its four floors. During an observation conducted on December 11, 2024, between 12:30 PM and 1:30 PM, various items were found stored in the egress corridors. On the 4th floor, side chairs, linen carts, and bed tables were observed throughout the corridor. Similarly, on the 3rd floor, side chairs, linen carts, bed tables, and a shredder container were found outside the Lounge/Dining Room. On the 2nd floor, two containers, each greater than 32 gallons, were located at the smoke doors by the Central Bath. An interview with the Director of Maintenance confirmed the facility's failure to keep the corridors clear and unobstructed.
Plan Of Correction
Various items such as chairs, linen carts, bed tables, and containers greater than 32 gallons throughout the corridors on each floor were removed and placed in appropriate locations. The Maintenance Director or Designee will re-educate employees on the expectation of keeping areas of exit free of all obstructions to full use in case of emergency. The Maintenance Director or Designee will do random monthly audits x 12 months of all floors to ensure aisles, passageways, corridors, and exits are free of all obstructions. The Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations x 12 months.
Non-compliance with Stairtower Door Standards
Penalty
Summary
The facility failed to maintain the stairtower doors in compliance with NFPA 101 standards on one of four floors. During an observation, it was noted that the 4th floor 2D stairtower door had gaps greater than the allowed 3/16 inch, which was confirmed by the Director of Maintenance. Additionally, the 4th floor 1D stairtower door had broken panic hardware, was patched, and could not be opened as it was held closed with a 2 x 4 on the stairtower side. This was also confirmed by the Director of Maintenance during the interview.
Plan Of Correction
The Maintenance Director will repair the 4th floor hallway 2D stair tower door so there is no gap greater than 3/16 inch. The Maintenance Director will secure a contractor to replace the 4th floor hallway 1D stair tower door. The facility is requesting a Time-Limited Waiver for 1D replacement to be completed no later than 5/10/2025. The Maintenance Director or Designee will audit all stair tower doors to ensure that there are no gaps greater than 3/16 inch. The Maintenance Director or Designee will audit all stair tower doors to ensure that the hardware is functioning properly. The Maintenance Director or Designee will do random monthly audits every 90 days of all stair tower doors to ensure that there are no gaps greater than 3/16 inch and that the hardware is functioning properly. The Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Non-compliance with Soiled Linen and Trash Container Standards
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the management of soiled linen and trash containers. During an observation on December 11, 2024, at 12:45 PM, it was noted that the facility had accumulated trash and soiled-linen containers totaling 32 gallons within a 64-square foot area on the 3rd floor Central Bath, near Resident Room 307. This accumulation was outside of a protected area, which is a violation of the requirement that such containers should not exceed 32 gallons in a 64-square foot area unless located in a room protected as a hazardous area. The Director of Maintenance confirmed the facility's failure to monitor and manage the amount of trash and soiled-linen containers appropriately.
Plan Of Correction
Maintenance removed all observed accumulated trash and soiled linen containers in the 3rd floor central bath. Maintenance Director or Designee will re-educate employees on the importance of not placing containers greater than 32 gallons in a 64-square foot area. Maintenance Director or Designee will complete weekly random audits of the bath areas to ensure there are no trash or solid linen containers in this area. Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Failure to Conduct Semi-Annual Kitchen Suppression System Testing
Penalty
Summary
The facility failed to comply with the requirement for semi-annual testing of the kitchen cooking facilities' suppression system. During a document review and observation conducted on December 11, 2024, it was found that the kitchen suppression system had only been inspected once on March 20, 2024, instead of the required semi-annual schedule. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the facility did not conduct the necessary inspection of the kitchen extinguishing system.
Plan Of Correction
Maintenance Director or Designee will schedule a kitchen suppression inspection with the designated company. Senior Maintenance Director will add the semi-annual testing of kitchen cooking facilities suppression system on the TELS maintenance system in order to monitor completion and compliance. Maintenance Director and Dietary Director will be re-educated on the regulation and timeframe of inspection of the suppression system. Maintenance Director or Designee will audit 2x year the inspection reports for compliance. Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner in both the dietary department and on one of the nursing units. During a kitchen tour, it was observed that multiple food items in various reach-in coolers were not dated, including chef salads, bags of cheddar cheese, lettuce, shredded carrots, diced tomatoes, diced potatoes, parmesan cheese, crushed pineapple, cinnamon rolls, cottage cheese, and whole milk. Additionally, there was dried food debris in the coolers, and in dry storage, an opened bag of dried breadcrumbs was found on top of a file cabinet with breadcrumbs on the floor. The food preparation area had bulk containers with food debris on the lids, and a scoop was found in the flour bin. The dish machine's chemical solution was below the required federal regulation level, and there was no documented evidence of tray line holding food temperatures being recorded since a specified date. On Nursing Unit 2, the resident pantry contained a beef patty in the freezer and various items in the refrigerator, such as an opened jar of pickles, mustard, pasta with red sauce, soup, a sandwich, soda, a bag with an opened bottle of dressing, salad containers, chocolate pudding, and dishes of pineapple, all of which were not labeled or dated. Interviews with the Dietary Manager and the Administrator confirmed the lack of proper labeling and removal of expired items, as well as the absence of documented tray line temperature records. The facility's failure to adhere to its food handling policies and federal regulations resulted in these deficiencies.
Plan Of Correction
1&2. The food items identified that were not dated or expired were discarded; dried food debris on the bottom of the cooler, and top of bulk containers in the food prep area were immediately cleaned when identified; the scoop was removed from the flour container. Ecolab visited when the problem was identified and observed that the sanitizer solution was being diluted by water from the dish machine, which was immediately remediated. The cook was verbally educated when the problem was identified; nursing staff discarded all food that was not properly labelled. 3. Dietary staff was re-educated on dating/labeling of all food and discarding expired food; properly cleaning food debris daily; removing scoop/utensils from food containers; monitoring the dish machine sanitizer level of 50ppm; timely recording of food holding temperatures on the trayline; nursing staff re-educated on properly labelling of food in resident's pantry refrigerators. 4. The NHA and/or designee will conduct weekly random audits for 90 days of food being stored in coolers to ensure dating is being completed; cleanliness of coolers and food prep areas; containers to ensure utensils aren't left in them; sanitizer logs and random tests; trayline food temperature logs are completed; and resident's pantry refrigerators for properly labelled food. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Deficiency in Dietary Services Management
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview on December 8, 2024, the dietary manager revealed that the facility did not have a certified dietary manager. This was further confirmed in an interview on December 10, 2024, when the Administrator acknowledged that there was no full-time dietitian employed onsite and that the facility lacked a qualified certified dietary manager to fill this role.
Plan Of Correction
1&2. The current dietary manager is scheduled to complete Dietary Manager Training coursework to obtain certification by 6/27/25. Nutraco continues efforts to hire a FT RD while supporting needs remotely. In addition, a job requisition was posted for FT RD at West Reading. 3. Re-education was completed to the NHA on the requirements of 0801. 4. NHA or designee will complete an initial audit x 90 days of the credentials of the newly hired Registered Dietitian to ensure compliance with 0801. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Follow Pre-Approved Menus
Penalty
Summary
The facility failed to adhere to pre-approved menus, as evidenced by resident interviews, facility documentation review, observations, and staff interviews. During a Resident Council interview, four residents reported that meal items were frequently substituted without prior notice. A review of the facility menus showed that on December 8, 2024, the lunch meal was supposed to include roasted potatoes, a dinner roll, and fruit pie, but residents received mashed potatoes, fruit ambrosia salad, and no dinner roll. On December 9, 2024, the menu indicated that fruit ambrosia salad should be served, but residents received applesauce instead. The Dietary Manager confirmed that the planned menu items were not served as intended.
Plan Of Correction
1&2 The pre-approved menus will be followed. If not, residents will be notified of substitutions via announcement & the daily posted menu. 3. The Director of Dining Services and dietary staff will be educated on following pre-approved menus. If substitutions are made, the residents will be notified via announcement & the daily posted menu. 4. The NHA and/or designee will complete weekly random audits x 90 days of posted menus and the substitution logs to ensure residents were notified. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as required by regulatory standards. Resident 16, who had a pressure ulcer in the sacral region, did not have interventions for this condition included in their care plan, despite it being noted in the Minimum Data Set (MDS) Care Area Assessment (CAA) summary. Similarly, Resident 48, diagnosed with obstructive uropathy and having an indwelling catheter, lacked a care plan addressing this issue, even though it was identified in the MDS CAA summary. Resident 132, who was admitted with neoplasm of the bladder and pancreas, cervicalgia, and migraines, was receiving daily scheduled pain medication, yet their care plan did not address pain management as noted in the MDS CAA summary. Additionally, Resident 143, who was frequently incontinent and had diagnoses including acute cerebrovascular insufficiency, cellulitis, and psoriasis, did not have their urinary incontinence addressed in the care plan, despite it being highlighted in the MDS CAA summary. The Director of Nursing confirmed these care areas were not addressed in the care plans during an interview.
Plan Of Correction
1. Care Plans for Residents 16, 48, 132, 143 were reviewed and updated. 2. An audit of current residents' Care Plans of all residents that have sacral wound, indwelling catheter, foley, pain will be reviewed to ensure they include a comprehensive plan of care with interventions that are individualized for each resident. 3. Licensed Nursing staff will be re-educated on the importance of reviewing and updating care plans and areas identified through the Care Assessment Area are completed in the resident care plan. 4. The DON and/or designee will complete weekly random audits x 90 days on five resident Care Plans to ensure areas identified in the CAA are contained on the resident care plan. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to deficiencies in care. Resident 16, diagnosed with hypotension, had a physician's order for midodrine to be administered three times a day on specific days, with the condition that it should not be given if the resident's systolic blood pressure (SBP) exceeded 130 mmHg. However, the medication was administered seven times in November and four times in December when the resident's SBP was above the specified limit. Resident 56, with diagnoses including cerebral infarction, chronic kidney disease, and chronic osteomyelitis, had a physician's order to be weighed weekly for four weeks and then monthly. The facility failed to document the resident's weight on three specified dates in November. The Director of Nursing confirmed these lapses in care during an interview.
Plan Of Correction
1. Resident 16's is receiving Midodrine according to physician orders. Resident 56 is being weighed according to physician orders. 2. An initial audit will be completed by the Director of Nursing/Designee on current residents with Midodrine orders to ensure they are receiving medication according to physician orders. An initial audit will be completed by the Director of Nursing/Designee on current residents to ensure weights completed according to facility policy or physician orders. 3. Licensed Nursing staff will be re-educated on following physician's orders with special attention to orders with parameters and weights. 4. The DON/designee will complete weekly random audits to ensure weights are completed according to facility policy or physician orders. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Implement Safety Interventions and Notify Physician
Penalty
Summary
The facility failed to implement safety interventions to prevent falls and did not notify the physician as required by their policy for a resident with cognitive impairment and mobility issues. The resident, who was at risk for falls due to hemiplegia, hemiparesis, and altered mental status, experienced multiple unwitnessed falls over a period of time. Despite these incidents, the facility did not put additional interventions in place to address the resident's fall risk. Furthermore, the facility's documentation lacked evidence of completed interventions such as a bowel and bladder assessment and safety checks every 15 minutes, which were supposed to be implemented after specific falls. Additionally, the physician was not notified of a fall on one occasion, contrary to the facility's policy. The Director of Nursing confirmed these lapses in safety interventions and communication with the physician.
Plan Of Correction
Resident 146 has safety interventions in place to prevent falls. Physician has been notified of any fall. An initial audit will be completed by the Director of Nursing/Designee on current residents who have fallen to ensure safety interventions were put in place and physicians have been notified of the fall. Licensed Nursing staff will be re-educated on following up to ensure fall interventions are in place, including documentation as needed and notification of the physician. Resident falls will be reviewed at clinical meetings to ensure safety interventions are implemented and physicians are notified when a fall occurs. The DON/designee will conduct a weekly random audit on five resident falls for 90 days to ensure safety interventions were implemented and the physician was notified. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were acted upon in a timely manner for two residents. Resident 79, who was admitted with diagnoses including Parkinsonism, dementia, and depression, had pharmacy recommendations made on multiple occasions from June to November 2024. However, there was no documentation indicating what these recommendations were for June, July, August, or September, nor any evidence that they were addressed by the physician. Similarly, Resident 149, admitted with syncope, hypertension, and dementia, had pharmacy recommendations made in September and November 2024, but there was no documentation of these recommendations or any indication that they were addressed by the physician. In an interview, the Director of Nursing confirmed the absence of documentation regarding specific pharmacy recommendations or their timely action. This deficiency was identified under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Plan Of Correction
Residents 79 & 149 pharmacy recommendations have been reviewed by the physician. An initial audit will be completed by the Director of Nursing/Designee on Pharmacy recommendations since 11/1/24 to ensure recommendations have been reviewed by the MD/CRNP and recommendations followed in a timely manner. Licensed Nursing staff will be re-educated by the Director of Nursing or designee on ensuring pharmacy recommendations are reviewed with MD/CRNP and followed up on in a timely manner. The DON and/or designee will complete weekly random audits x90 days on pharmacy recommendations to ensure they were followed up on. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Medication Storage Deficiency in Nursing Unit
Penalty
Summary
The facility failed to properly store medications in one of its nursing units, specifically the Second Floor Nursing Unit. During an observation of a medication cart used for resident rooms 218 through 229, it was found that four insulin lispro pens, one insulin glargine pen, one Semglee insulin pen, and one Basaglar insulin pen were opened and not labeled with an open date. This was confirmed by an LPN who acknowledged that the insulin pens should have been labeled. Additionally, the medication storage room refrigerator contained an opened vial of Tubersol that was not labeled, despite being in a storage box labeled for discard by a specific date. Further inspection revealed three bottles of doxycycline labeled with a do-not-use-after date and a large container of glycerin suppositories labeled for a resident who had expired. The Director of Nursing confirmed that staff were required to label all medications with open and expiration dates and to remove all expired or discontinued medications from the medication cart and storage room refrigerator. These findings indicate a failure to adhere to the facility's policy on medication storage, potentially compromising medication safety and efficacy.
Plan Of Correction
1. The four insulin pens that were opened were not dated, the TB vaccine in the refrigerator opened and not dated, the three bottles of expired doxycycline, and outdated Glycerin suppositories were all removed and disposed of per policy. 2. An initial audit will be completed by the Director of Nursing/Designee on Medication refrigerator, carts and medication rooms to ensure medications are stored and labeled appropriately. 3. Licensed Nursing staff will be re-educated by the director of nursing or designee on the facility "Storage of medication" policy. 4. Unit Managers/RN Supervisors will conduct weekly random audits x 90 days med carts and med rooms to assure medications are stored and labeled appropriately. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital. This deficiency was identified for eight residents who were transferred due to changes in their medical conditions. The clinical records for these residents did not contain documentation that the residents or their responsible parties were informed in writing about the transfers, the reasons for the transfers, or provided with Ombudsman information. The residents affected by this deficiency were transferred to the hospital on various dates throughout 2024. Despite the changes in their conditions necessitating these transfers, there was no evidence that the facility complied with the requirement to notify the residents or their representatives in writing. The facility's administrator confirmed during an interview that the required written notices were not provided, indicating a systemic issue in the facility's transfer notification process.
Plan Of Correction
1. Residents 39, 85, 89, 94, 143, 146, and 157, their responsible party, or legal representative were provided with the facility Transfer notice. 2. An initial audit will be completed by the NHA/Designee on residents that have been transferred out of the facility to an acute care facility since 12/10/24 to ensure their responsible party, or legal representative, was provided with the Transfer notice. 3. Licensed nursing staff will be re-educated on the Discharge/Transfer Policy and process by the DON and/or Designee. Residents transferred out of the facility will be reviewed at clinical meetings to ensure the RP has been provided with the transfer notice. 4. The NHA and/or designee will complete a random weekly audit x 90 days of Residents who have transferred to the hospital to ensure transfer notices were provided to them, their responsible party, or legal representative. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During a tour of the facility on December 8, 2024, it was observed that the staffing information displayed in the lobby was outdated, showing the date of December 6, 2024. This discrepancy was confirmed in an interview with the Administrator on December 10, 2024, who acknowledged that the posted staffing data was incorrect.
Plan Of Correction
1 & 2. The accurate and current nurse staffing information is now posted daily. 3. Nurse supervisors and the Scheduler/Payroll Manager will be re-educated by the NHA on posting accurate and current nurse staffing information daily. 4. The NHA and/or designee will complete weekly random audits for 90 days of posted nurse staffing information. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed in the dumpster area. On December 8, 2024, at 9:45 a.m., multiple pieces of crushed plastic and cardboard debris, crushed Styrofoam containers, and used gloves were found scattered around the outside of both dumpsters. Additionally, one dumpster had two lids on top, with one lid wide open and the other lid supporting two full bags of garbage.
Plan Of Correction
1 & 2 Upon notification, the area was immediately cleared of trash and refuse. 3. The Director of Dining Services and dietary staff will be re-educated on maintaining a trash and refuse free dumpster area. 4. The NHA and/or designee will complete weekly random audits x 90 days of the dumpster area to ensure it remains free of trash and refuse. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified by the regulation effective July 1, 2024. A review of nursing schedules for 21 days across September, October, and December 2024 revealed that the facility did not meet the required staffing levels on multiple occasions. Specifically, the day shift ratio of one NA per ten residents was not met on nine days, and the evening shift ratio of one NA per eleven residents was not met on eight days. These deficiencies were identified through a detailed examination of the nursing time schedules, indicating a consistent shortfall in staffing levels over the reviewed periods.
Plan Of Correction
1 & 2. Education given to the Nurse Scheduler on the Certified Nursing Aides ratio requirements of 1 NA to 10 residents on day shift, 1 NA to 11 residents on evening shift, and 1 NA to 15 residents on night shift. 3. The facility is actively recruiting Certified Nurses Aides; utilizing Nurse Agency to supplement Certified Nursing Aides; recruiting Nursing Aides for classes and training with intent to hire when qualified; and staffing meetings conducted in attempts to maintain State Mandated ratios for Certified Nursing Aides. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of Certified Nursing Aides are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Staffing Ratio Deficiencies in Nursing Services
Penalty
Summary
The facility failed to meet the required nursing assistant (NA) to resident ratio of one NA for 15 residents during the night shift on September 1 and 2, and December 7, 2024. Additionally, the facility did not comply with the minimum licensed practical nurse (LPN) to resident ratios on several occasions. Specifically, the facility did not meet the required ratio of one LPN for 25 residents during the day shift on October 27, 2024. Furthermore, the facility failed to maintain the required ratio of one LPN for 30 residents during the evening shift on December 4 and 7, 2024, and did not meet the ratio of one LPN for 40 residents during the night shift on September 7, 2024. These deficiencies were identified based on a review of nursing time schedules over a period of 21 days, including September 1 through 7, October 25 through 31, and December 3 through 9, 2024. The failure to maintain these staffing ratios indicates a breach in regulatory compliance regarding the provision of adequate nursing services during specified shifts.
Plan Of Correction
1 & 2. Education given to the Nurse Scheduler on the LPN ratio requirements of 1 LPN to 25 residents on day shift, 1 LPN to 30 residents on evening shift, and 1 LPN to 40 residents on night shift. 3. The facility is actively recruiting LPNs; utilizing Nurse Agency to supplement LPNs; and staffing meetings conducted in attempts to maintain State Mandated ratios for LPNs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of LPNs are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of nursing schedules over a 21-day period, specifically on eight days. On these days, the facility provided less than the required hours of care, with the lowest being 2.63 hours per resident. The specific dates where the care hours fell below the mandated minimum were September 1 and 7, October 26 and 27, and December 6, 7, 8, and 9, 2024. These findings indicate a consistent shortfall in meeting the required staffing levels to ensure adequate resident care during the specified periods.
Plan Of Correction
1 & 2. Education given to the Nurse Scheduler on the PPD requirements of 3.2 hours of direct care for each resident. 3. The facility is actively recruiting CNAs & LPNs; utilizing Nurse Agency to supplement CNAs & LPNs; recruiting Nursing Aides for classes and training with intent to hire when qualified; and staffing meetings conducted in attempts to maintain State Mandated ratios for LPNs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the facility is staffed appropriately to reach the mandated State PPD. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.
Failure to Notify Responsible Party of Treatment Change
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in treatment, which is a requirement according to the facility's policy. The policy, last reviewed on July 1, 2024, mandates immediate notification to the resident's representative when there is a need to significantly alter treatment. Clinical records revealed that a resident with diagnoses including respiratory failure, mild cognitive impairment, pulmonary disease, and anxiety disorder experienced increased shortness of breath, congestion, and wheezing. On September 24, 2024, a physician ordered azithromycin to be administered daily for five days due to the unresolved condition. However, there was no evidence that the resident's responsible party was informed of this change in the treatment plan. Interviews with the Director of Nursing confirmed the oversight in notification.
Failure to Store Food Properly in Dietary Department and Nursing Units
Penalty
Summary
The facility failed to store food in a sanitary manner in the dietary department and on three nursing units, as observed during a survey. Dietary Employee 1 stated that all foods should be labeled with the date they were opened, and processed meats should be discarded seven days after opening. However, during a kitchen tour, several items were found without dates, including dry cereal, strawberries, sliced lemons, diced ham, turkey lunch meat, pancakes, and hot dogs. Dietary Employee 1 confirmed that these items should have been dated and expired items removed. Additionally, observations in the resident pantries on the Second, Third, and Fourth floors revealed multiple food items that were not labeled with a resident's name or date. These included ice cream, packaged meals, condiments, and beverages. Registered Nurse 1 confirmed that the unit pantries are for resident food only and that items should be labeled with the resident's name and dated. The facility's policy requires refrigerated foods to be labeled with the resident's name and date, which was not adhered to in these instances.
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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