Westgate Hills Rehabilitation And Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Havertown, Pennsylvania.
- Location
- 2050 Old West Chester Pike, Havertown, Pennsylvania 19083
- CMS Provider Number
- 395173
- Inspections on file
- 20
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Westgate Hills Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
A resident's room was found to have a window with broken glass pieces taped with duct tape and additional broken glass between the glass panel and screen. The same room also contained a dresser with two broken drawer fronts, with the broken pieces left inside the drawers. These issues were confirmed by the DON during observation, indicating a failure to provide a safe environment.
The facility failed to maintain its sprinkler system, with deficiencies including non-reporting tampers, an overdue FDC hydrotest, and an improperly piped dry system main drain. These issues were confirmed during document reviews and exit interviews with facility administrators.
The facility failed to maintain the fire rating of a storage area on the first floor near a resident room, as it lacked a self-closing door. This deficiency was observed on two separate occasions and confirmed by facility administrators.
The facility failed to conduct monthly inspections of the kitchen hood suppression system on the first floor, as required by NFPA 101. This deficiency was initially observed in November and confirmed during an exit interview with the Administrator and Maintenance Director. A revisit in January showed the issue persisted, confirmed again in an exit interview with the Administrator and Regional Maintenance Director.
Westgate Hills Rehabilitation and Nursing Center was found deficient in their Emergency Preparedness Plan, lacking policies and procedures for persons at-risk. This issue was identified during a document review and confirmed in interviews with the Administrator and Maintenance Director. A subsequent revisit showed the deficiency remained unaddressed.
The facility failed to provide necessary policy and procedure documentation regarding its role under a waiver declared by the Secretary, as required by section 1135 of the Act. This deficiency was identified during a document review and confirmed in interviews with the Administrator and Maintenance Director. A follow-up revisit showed the issue remained unaddressed.
The facility failed to develop and maintain an emergency preparedness training and testing program based on its emergency preparedness plan. This deficiency was confirmed during document reviews and exit interviews with facility administrators, indicating non-compliance with the requirement to review and update the program annually.
The facility failed to conduct one of the two required annual exercises to test its emergency preparedness plan, as revealed during a document review. Despite performing a full-scale exercise, the facility did not conduct the additional required exercise, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, and a follow-up revisit showed the issue remained unaddressed.
The facility failed to maintain and inspect portable fire extinguishers as per NFPA 10 standards. They could not provide certification for the inspector conducting the annual inspection, and a fire extinguisher was found blocked by wheelchairs. These issues were confirmed during interviews with the Administrator and Maintenance Director.
A facility failed to follow physician's orders for a resident's medication, Metoprolol, which was administered 23 times despite the resident's heart rate being below the prescribed threshold. The resident had Chronic Systolic Heart Failure and Paroxysmal Atrial Fibrillation, and the issue was confirmed by the DON and Nursing Home Administrator.
A resident experienced a significant weight loss while on enteral feeding, dropping 9.8 pounds in less than a month. The facility failed to re-weigh the resident or address the weight change in a timely manner, with the dietitian taking seven days to respond and the physician being notified two weeks later. This delay violated the facility's policy and regulatory requirements.
A facility failed to ensure that medication irregularities identified during monthly drug regimen reviews were acted upon by a physician for a resident with severely impaired cognition and multiple medical diagnoses. Despite recommendations from the pharmacist to evaluate the use of certain medications, the physician signed the reports without responding or indicating any action taken. This deficiency was confirmed by the DON.
Failure to Maintain Safe Resident Room Environment
Penalty
Summary
A deficiency was identified when observations and staff interviews revealed that a resident's room on the Rehabilitation Unit had a window with broken glass pieces that were taped with duct tape, and additional broken glass pieces were found between the glass panel and the screen. Further inspection of the same room showed a dresser with two broken drawer fronts, with the broken pieces placed inside the drawers. These conditions were confirmed by the DON during the observation. The facility failed to provide a safe environment for the resident as required by regulations.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire facility. During a document review on November 20, 2024, it was found that the fourth quarter sprinkler inspection revealed several deficiencies that had not been corrected. Specifically, the tampers in the backflow preventer pit were not reporting to the fire alarm panel, the FDC hydrotest was overdue, and the dry system main drain was improperly piped to a shower drain that could not handle the full flow from the drain. These issues were confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up onsite revisit conducted on January 8, 2025, confirmed that the same deficiencies remained unaddressed. The tampers in the backflow preventer pit still did not report to the fire alarm panel, the FDC hydrotest was still overdue, and the dry system main drain continued to be piped to a shower drain incapable of handling the full flow. These ongoing deficiencies were again confirmed during an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K353: Sprinkler System Maintenance and Inspection 1. Deficiency: Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the following deficiencies noted during the fourth quarter sprinkler inspection, with no documentation of the correction of these issues: a. Tampers in the backflow preventer pit were not reporting to the fire alarm panel. b. FDC hydrotest is overdue. c. Dry system main drain is piped to a shower drain, which cannot handle the full flow from the drain (note: this was not considered a deficiency, but a note). Residents Affected: No residents were directly affected by these deficiencies. However, all residents have the potential to be affected if these issues with the sprinkler system are not addressed properly, as the sprinkler system is a key safety feature for the entire facility. 2. Corrective Action: a. The necessary repairs will be made to ensure that the tampers in the backflow preventer pit report to the fire alarm panel. This repair will be completed by 02/08/25. b. The FDC hydrotest was completed on 12/27/24. c. The issue with the dry system main drain was identified as a note by the inspector and is not considered a deficiency. An addendum to the original report will be obtained from the sprinkler inspection vendor indicating that the main drain item is not considered a "deficiency" and was identified as a note. This documentation will be available to review by the life safety inspector on the day of the revisit. 3. Monitoring: The Maintenance Director will ensure that the sprinkler system, including the backflow preventer and fire alarm panel connections, is fully functional and reporting correctly. A follow-up audit will be conducted on 02/08/25 to ensure all necessary corrections have been completed and that the sprinkler system is in full compliance. 4. Timeline: The repairs for the tampers in the backflow preventer pit will be completed by 02/08/25. The FDC hydrotest has been completed as of 12/27/24.
Failure to Maintain Fire Safety in Storage Area
Penalty
Summary
The facility failed to maintain the fire rating of storage areas, specifically on the first floor near resident room 131. During an observation on November 20, 2024, it was noted that the storage room lacked a self-closing mechanism on its door, which is a requirement for maintaining the fire resistance rating of hazardous areas. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the deficiency had not been corrected, as the storage room near resident room 131 still lacked a self-closing door. This was again confirmed in an exit interview with the Administrator and the Regional Maintenance Director. The failure to address this issue indicates a continued non-compliance with the fire safety requirements for hazardous areas.
Plan Of Correction
Plan of Correction for TAG K321: Fire Safety - Storage Area Self-Closing Door 1. Deficiency: Based on observation and interview, it was determined that the facility failed to maintain the fire rating of storage areas, affecting one of three levels within the facility. Observation on November 20, 2024, at 10:44 a.m., revealed that on the first floor, the storage room near resident room 131 lacked a self-closing door. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of a self-closing door. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of a fire emergency if fire safety regulations are not fully met. 2. Corrective Action: The self-closing door was installed in the storage room near resident room 131 to maintain the required fire rating for the area. The Maintenance Director verified that all other storage areas are in compliance with fire safety regulations. 3. Monitoring: Weekly audits will be conducted for 4 weeks to ensure continuous compliance with fire safety regulations, including verification of the self-closing door installation and proper function. Findings will be documented, and any necessary corrective actions will be taken. 4. Timeline: The self-closing door was installed on 01/08/25. Weekly audits will be completed for 4 weeks starting from 01/28/25.
Failure to Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which is a requirement under NFPA 101 for cooking facilities. During an observation on November 20, 2024, it was noted that the kitchen hood suppression system on the first floor lacked the necessary monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the issue persisted, as the kitchen hood suppression system still lacked monthly inspections. This was again confirmed in an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K324: Kitchen Hood Suppression System 1. Deficiency: Based on observation and interview, it was determined that the facility failed to maintain and inspect the kitchen hood suppression system, affecting one of three levels in the facility. Observation on November 20, 2024, at 10:33 a.m., revealed that on the first floor, the kitchen hood suppression system lacked monthly inspections. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the missing monthly inspections. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the kitchen hood suppression system is not properly maintained and inspected in case of a fire emergency. 2. Corrective Action: The facility will conduct a thorough inspection of the kitchen hood suppression system immediately. Monthly inspections will be implemented going forward, and a log will be maintained to track the inspections. 3. Monitoring: The Maintenance Director will ensure that the kitchen hood suppression system is inspected monthly. Monthly audits will be conducted for 3 months to ensure compliance with the kitchen hood suppression system inspection requirement. 4. Timeline: The inspection will be completed by 01/28/25. Monthly inspections will continue, with audits conducted for 3 months to ensure ongoing compliance.
Deficiency in Emergency Preparedness Plan at Westgate Hills
Penalty
Summary
Westgate Hills Rehabilitation and Nursing Center was found to have deficiencies in their Emergency Preparedness Plan during a revisit survey. The facility failed to include policies and procedures addressing the patient population, specifically persons at-risk, in their emergency preparedness documentation. This deficiency was identified during a document review on November 20, 2024, and confirmed during an exit interview with the Administrator and the Maintenance Director. A subsequent onsite revisit conducted on January 8, 2025, revealed that the facility still had not addressed the missing documentation in their Emergency Preparedness Plan. The plan continued to lack policies and procedures for persons at-risk, affecting the entire facility. This was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG E0007: Emergency Preparedness Plan - Patient Population and Continuity of Operations 1. Deficiency: Based on document review and interview, the facility failed to ensure policies and procedures were in place addressing patient population, including but not limited to persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the Facility's Emergency Preparedness Plan did not include policies and procedures addressing persons at-risk. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the missing documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of an emergency where these provisions are required. 2. Corrective Action: The facility will update its Emergency Preparedness Plan to include: - Policies and procedures addressing persons at-risk within the patient population. - A clear description of the types of services the facility is able to provide in the event of an emergency. - Continuity of operations, including delegation of authority and succession plans for key personnel to ensure continued operation during an emergency. 3. Monitoring: The Emergency Preparedness Plan will be reviewed annually to ensure it includes all necessary policies and procedures for the patient population, including those at risk, and for continuity of operations. Any updates or changes will be presented to the Quality Assessment and Assurance Committee for review and approval. 4. Timeline: The Emergency Preparedness Plan will be updated by 01/28/25, with an annual review thereafter.
Failure to Provide Emergency Preparedness Documentation
Penalty
Summary
The facility failed to provide the necessary policy and procedure documentation concerning its role under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m., where it was found that the facility could not produce the required Emergency Preparedness Plan documentation. This documentation is crucial for outlining the facility's responsibilities in providing care and treatment at an alternate care site as identified by emergency management officials. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., revealed that the facility still had not addressed the issue, as the necessary documentation was still unavailable. This was further confirmed in an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day.
Plan Of Correction
Plan of Correction for TAG E0026 - Scope C: Emergency Preparedness Plan 1. Deficiency: A document review on November 20, 2024, at 8:00 a.m. revealed that the facility could not provide Emergency Preparedness Plan policy and procedure documentation concerning the roles under a waiver declared by the Secretary. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected in the event of an emergency situation where the waiver provisions need to be implemented. 2. Corrective Action: The facility will review and update its Emergency Preparedness Plan to include: - Roles and responsibilities of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act. - Procedures for the provision of care and treatment at an alternate care site identified by emergency management officials, if necessary. 3. Monitoring: The Emergency Preparedness Plan will be reviewed annually to ensure continued compliance with updated policies and procedures. Any necessary updates will be presented to the Quality Assessment and Assurance Committee for review and approval. 4. Timeline: The Emergency Preparedness Plan will be reviewed and updated by 1/28/25, with an annual review thereafter.
Failure to Develop Emergency Preparedness Training Program
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program based on its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, at 8:00 a.m. The review revealed that the facility did not have the necessary documentation to support the existence of such a program. This issue affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director on the same day. A follow-up onsite revisit on January 8, 2025, between 12:00 p.m. and 12:30 p.m., confirmed that the facility still had not developed or maintained the required emergency preparedness training and testing program. The lack of documentation was again confirmed during an exit interview with the Administrator and the Regional Maintenance Director at 12:45 p.m. on the same day. This ongoing deficiency indicates a failure to comply with the regulatory requirement to review and update the program at least annually.
Plan Of Correction
Plan of Correction for TAG E0036: Emergency Preparedness Training and Testing 1. Deficiency: Based on documentation review and interview, it was determined that the facility failed to develop an emergency preparedness training program that is based on the facility's emergency preparedness plan. The training and testing program must be reviewed and updated at least annually, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that aligns with the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's staff is not properly trained in emergency preparedness protocols. 2. Corrective Action: The facility will develop and implement an emergency preparedness training program based on the facility's updated emergency preparedness plan. The training program will include testing procedures and will be reviewed and updated at least annually to ensure ongoing compliance. 3. Monitoring: The facility will track and document all training sessions, including the participation of all relevant staff members. An annual review of the training program will be conducted to ensure that it remains aligned with the current emergency preparedness plan and includes all necessary updates. 4. Timeline: The emergency preparedness training program will be developed and implemented by 01/28/25, with annual reviews thereafter.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to meet the emergency preparedness testing requirements as outlined in §483.73(d)(2). Specifically, the facility did not conduct one of the two required annual exercises to test its emergency preparedness plan. This deficiency was identified during a document review conducted on November 20, 2024, which revealed that within the previous 12 months, the facility had only performed a full-scale exercise and did not conduct the additional required exercise. During an exit interview on the same day, the Administrator and the Maintenance Director confirmed the lack of an additional exercise. This oversight affected the entire facility, as the emergency preparedness plan was not fully tested as required by the regulations. The absence of the additional exercise meant that the facility did not fully comply with the regulatory requirements for emergency preparedness testing. A follow-up onsite revisit conducted on January 8, 2025, confirmed that the deficiency had not been addressed. The document review during this revisit showed that the facility still had not performed the additional required exercise within the previous 12 months. The Administrator and the Regional Maintenance Director confirmed this ongoing deficiency during an exit interview on the same day.
Plan Of Correction
1. Deficiency: Based on document review and interview, it was determined that the facility failed to conduct one of the two required annual exercises to test the facility's emergency preparedness plan, affecting the entire facility. Document review on November 20, 2024, at 8:00 a.m., revealed that within the previous 12 months, the facility performed only a full-scale exercise and did not perform the additional required exercise to test the emergency preparedness plan. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of the additional exercise. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the facility's emergency preparedness plan is not properly tested through regular exercises. 2. Corrective Action: The facility will conduct the additional required annual exercise, ensuring that both a full-scale exercise and a tabletop exercise (or another approved exercise) are completed within the required time frame to properly test the emergency preparedness plan. A schedule will be developed to ensure that future exercises are performed on time and documented accordingly. 3. Monitoring: The facility will track the completion of required exercises and ensure they are conducted annually as per regulations. Documentation of each exercise, including participant involvement and outcomes, will be reviewed by the Quality Assessment and Assurance Committee. 4. Timeline: The additional required exercise will be completed by 01/28/25. Future exercises will be scheduled and conducted annually, with documentation reviewed for compliance.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10 standards, affecting the entire facility. During a document review on November 20, 2024, the facility was unable to provide certification for the inspector who conducted the annual inspection of the portable fire extinguishers. Additionally, an observation on the same day revealed that a portable fire extinguisher on the first floor, next to resident room 125, was obstructed by wheelchairs. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up revisit on January 8, 2025, showed that the facility still could not produce the required certification for the inspector, as confirmed in an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K355: Portable Fire Extinguishers 1. Deficiency: Based on document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility. Findings include: Document review on November 20, 2024, at 8:00 a.m., revealed the facility could not produce the certification for the inspector conducting the annual portable fire extinguisher inspection. Observation on November 20, 2024, at 10:42 a.m., revealed that on the first floor, the portable fire extinguisher next to resident room 125 was blocked by wheelchairs. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation and the blocked fire extinguisher. Residents Affected: No residents were directly affected by these deficiencies. However, all residents have the potential to be affected in the event of a fire emergency if fire extinguishers are not properly maintained or accessible. 2. Corrective Action: 1. The certificate for the inspector conducting the annual portable fire extinguisher inspection was obtained and filed on 01/08/25. 2. The portable fire extinguisher located next to resident room 125 was immediately cleared of all wheelchairs and is now accessible. 3. Monitoring: The Maintenance Director will review the portable fire extinguisher inspection records to ensure that certifications are maintained properly. Monthly inspections will be conducted to ensure all fire extinguishers are accessible and not blocked by any items, with audits documented. 4. Timeline: The certificate for the fire extinguisher inspector was obtained and filed on 01/08/25. The wheelchairs were removed, and the fire extinguisher is now accessible as of 11/20/24. Ongoing monthly checks will be conducted to ensure compliance.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders for medications were followed for one resident. Specifically, the facility did not adhere to the prescribed parameters for administering Metoprolol Succinate Extended Release to a resident with Chronic Systolic Heart Failure and Paroxysmal Atrial Fibrillation. The physician's order required the medication to be held if the resident's systolic blood pressure was below 105 mmHg or if the heart rate was less than 60 beats per minute. Upon review of the Medication Administration Record for October 2024, it was found that Metoprolol was administered 23 times when the resident's heart rate was below 60 beats per minute. This was confirmed through an interview with the Director of Nursing and the Nursing Home Administrator, who acknowledged that the staff did not follow the physician-ordered parameters for the medication administration.
Failure to Address Significant Weight Change
Penalty
Summary
The facility failed to timely and appropriately address a significant weight change for Resident 93, who was receiving continuous enteral feeding via a gastrotomy tube. The resident experienced a significant weight loss of 9.8 pounds, or 7.54%, in less than a month, dropping from a baseline weight of 130 pounds to 120.2 pounds. Despite the facility's policy requiring re-weighing and timely intervention by the dietitian and interdisciplinary team, the resident was not re-weighed after the weight change was identified on October 16, 2024. Furthermore, the dietitian did not address the significant weight change until October 23, 2024, seven days after it was first identified. The facility's policy also mandates notifying the resident's physician and responsible party of any significant weight changes. However, the physician was not informed of the weight loss until November 1, 2024, two weeks after the significant weight change was identified. The Director of Nursing (DON) reported that re-weighing should occur immediately after a weight change is identified and that nursing staff are responsible for notifying the physician. The DON was informed of the weight loss by the dietitian on October 30, 2024. This delay in addressing the weight change and notifying the physician constitutes a failure to comply with the facility's policy and regulatory requirements.
Failure to Act on Medication Irregularities
Penalty
Summary
The facility failed to ensure that medication irregularities identified during the monthly drug regimen review were acted upon by a physician for one resident. The resident, who was admitted to the facility with a severely impaired cognition as indicated by a BIMS score of 5, had multiple medical diagnoses including restlessness, agitation, unspecified dementia with behavioral disturbance, cognitive communication deficit, Alzheimer's disease, unspecified protein calorie malnutrition, and nutritional deficiency. The resident had physician orders for Mirtazapine for appetite, Lorazepam for anxiety, and Quetiapine for insomnia. Despite the pharmacist's recommendations during the medication record reviews conducted in July, August, and September 2024, which included evaluating the use of Mirtazapine for appetite without a depression diagnosis and the use of Quetiapine for insomnia, the physician merely signed the pharmacy recommendation reports without any response or indication that the recommendations were acted upon. This inaction was confirmed by the Director of Nursing during an interview, highlighting a deficiency in the facility's process for addressing medication irregularities.
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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