Westminster Woods At Huntingdo
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntingdon, Pennsylvania.
- Location
- 360 Westminster Drive, Huntingdon, Pennsylvania 16652
- CMS Provider Number
- 396015
- Inspections on file
- 30
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Westminster Woods At Huntingdo during CMS and state inspections, most recent first.
A cognitively intact, fully care-dependent resident with vascular ALS, bowel and bladder incontinence, and multiple skin issues alleged that he had not been changed for several hours. Staff later found his brief and bedding saturated with urine and a bowel movement present, and his call bell placed out of reach at the top of the bed. An RN assessment documented non-blanchable and blanchable areas on the thigh and open excoriations on the abdominal fold and groin. Investigation revealed that the assigned CNA did not provide care because the resident had not used the call bell, and the facility substantiated neglect based on this failure to provide necessary incontinence care.
The facility was found to have multiple deficiencies in food safety and staff hygiene. An opened box of frozen fish fillets was improperly stored, and a deep fryer was not cleaned after use, violating the facility's policies. Additionally, a staff member with a full beard was observed without a beard restraint during food preparation, contrary to the dress code guidelines.
The facility failed to notify a resident's responsible party about a downgrade in diet consistency after a choking incident and did not inform a urologist about UTI symptoms in another resident. Both residents were cognitively intact, and the deficiencies were confirmed by the DON.
A facility failed to develop a care plan for a resident requiring treatment for an infection using a PICC line for IV antibiotics. The resident was admitted for further care of a left heel wound and had orders to receive Ertapenem daily through the PICC line. However, no care plan was documented for the PICC line, infection, or IV antibiotics, as confirmed by the Nursing Home Administrator.
A facility failed to follow physician's orders for a resident with heart failure and high blood pressure. The resident's care plan required specific administration of Carvedilol and Lisinopril based on apical pulse readings. On several occasions, the facility either administered Carvedilol without checking the pulse or withheld Lisinopril against the orders. The DON confirmed these discrepancies.
A facility failed to provide a privacy cover for a resident's indwelling urinary catheter, as required by policy. The resident, who had a neurogenic bladder, was observed with an uncovered catheter collection bag, and the nurse aide confirmed the absence of a privacy bag. The Director of Nursing acknowledged the catheter tubing should not have been in contact with the fall mat.
A resident's medication, specifically 25 mg of Seroquel, was found on the floor in her bathroom, contrary to the facility's policy that medications should be stored in designated areas. The resident, who was cognitively intact and required assistance for daily care needs, was scheduled to receive the medication in the evening. An LPN confirmed the medication should not have been on the floor, and the DON acknowledged the error, indicating a failure in medication storage practices.
The facility failed to ensure that residents were offered and/or received necessary vaccinations. A resident did not receive the pneumococcal vaccine despite consenting, and two residents did not receive the influenza vaccine, with one not being documented as offered the vaccine. These issues were confirmed through staff interviews and record reviews.
A resident with severe cognitive impairment and vascular dementia was subjected to sexual abuse by a maintenance worker, who was observed by two nurse aides straddling, hugging, and rubbing the resident's flank area under her shirt. The incident was documented by staff and confirmed through interviews, indicating a failure to uphold the facility's abuse prevention policy.
A resident with severe cognitive impairment was recorded on a staff member's personal cell phone without consent during an incident where a maintenance worker was observed hugging and touching the resident under her shirt. The recording was made by a nurse aide who witnessed the event and believed it was necessary to document the situation. Facility policy prohibits the use of personal cell phones and requires protection of resident privacy and rights.
A resident with cognitive impairment and a history of stroke experienced a fall and subsequent changes in condition, but the required nursing assessments were not documented in the clinical record. The Director of Nursing confirmed the assessments were completed but not recorded, violating federal and state regulations for maintaining complete and accurate medical records.
A resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Neurological checks were initiated, and the resident was later admitted to the hospital with a stroke diagnosis. The facility failed to notify the Department of Health about this incident until contacted by Adult Protective Services.
A facility failed to create a comprehensive care plan for a resident with frequent UTIs, despite physician's orders for various medications and treatments. The resident's MDS assessment indicated frequent urinary incontinence, but no care plan was documented to address their condition, as confirmed by the DON.
The facility did not complete monthly pharmacy medication reviews for two residents, as required by their policy. The policy requires timely communication of pharmacist recommendations and a response before the next review. For two residents, there was no evidence that the December and January reviews were addressed by the physician. The DON confirmed the lack of documentation during an interview.
A facility failed to protect a resident's health information during medication administration. An LPN left a computer screen displaying a resident's personal health information unsecured and visible in the hallway. Both the LPN and the DON confirmed that the information should have been covered.
A resident with chronic kidney disease and hypertension had an elevated blood pressure reading of 197/86 mm/Hg, which was not reassessed as required by professional standards. Nursing staff confirmed that such a reading should have prompted further evaluation and documentation, but this did not occur.
A resident, who is cognitively impaired and requires moderate assistance, was transported in a wheelchair without leg rests by an RN. The RN acknowledged knowing the requirement to use leg rests, and the DON confirmed that all staff should use them during transport.
A facility failed to document the rationale for the long-term use of Zyprexa for a resident with severe cognitive impairment and diagnoses of depression and dementia. Despite federal regulations requiring as-needed orders for psychotropic drugs to be limited to 14 days, the resident continued to receive Zyprexa without documented justification. The Director of Nursing confirmed the absence of necessary documentation from the attending physician or psychiatric consultant.
The facility failed to secure a medication cart and properly label medications. An LPN left a medication cart unlocked and unattended, and controlled medications were not stored in a permanently-affixed compartment. Additionally, medications like Tubersol and Insulin Lispro were not labeled with the date they were opened, as confirmed by nursing staff.
The facility failed to prevent the elopement of two residents identified as at risk for elopement. One resident exited through the front door due to a receptionist's unawareness, and another resident exited during a fire alarm when door magnets were deactivated. Both residents were found outside and brought back without injuries.
Failure to Provide Timely Incontinence Care and Maintain Call Bell Access
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from neglect when assigned care was not provided over an extended period. The resident, who was dependent on staff for daily care, incontinent of bowel and bladder, and diagnosed with vascular ALS, alleged that he had not received proper care and had not been changed for about six hours. A quarterly MDS indicated that the resident was able to understand and be understood, but required staff for all daily care needs. On the evening in question, the resident reported to a nurse aide that he had been lying in bed for six hours without assistance. A subsequent RN assessment documented that the resident’s incontinence brief and bedding were saturated and that his call bell was not within reach, being located at the top of the bed. The assessment also identified multiple skin issues, including a non-blanchable purple area and a blanchable red area on the left thigh, and open excoriated areas on the abdominal fold and right groin. Investigation interviews confirmed that the assigned nurse aide did not provide care because the resident had not used the call bell, despite his dependence on staff for care. Other staff reported finding the resident with urine-saturated linens and a bowel movement present before providing incontinence care and changing all bedding. The facility’s investigation concluded that the allegation of neglect was substantiated based on the nurse aide’s failure to provide care.
Deficiencies in Food Safety and Staff Hygiene
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and staff hygiene. During an inspection, it was observed that an opened box of frozen fish fillets was left exposed to the air in the kitchen's walk-in freezer, contrary to the facility's policy requiring bulk freezer items to be properly sealed. This was confirmed by the Dietary Director, who acknowledged that the fish fillets should have been covered. Additionally, the deep fryer in the meal preparation area was found to have a large amount of floating fried debris, indicating it had not been cleaned after use, which is a violation of the facility's policy on sanitizing equipment to prevent food-borne illness. Furthermore, the facility's dress code guidelines were not followed, as observed during a tray line service where a staff member with a full beard and mustache was not wearing a beard restraint while preparing drinks and trays. This was in direct violation of the facility's policy that requires facial hair restraints for staff involved in food production. The Dietary Director confirmed that staff were expected to wear appropriate hair restraints, highlighting a lapse in enforcing hygiene standards during food preparation.
Failure to Notify Responsible Parties and Urologist of Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about changes in diet consistencies and failed to inform a urologist about symptoms of a urinary tract infection (UTI) for two residents. Resident 10, who was cognitively intact and dependent on staff for care needs, experienced a choking incident on water during medication administration. As a result, the resident's diet was downgraded from thin liquids to nectar thick liquids. Despite this significant change, there was no documented evidence that the resident's responsible party was informed about the downgrade in diet consistency after the incident or following a speech therapy assessment. Resident 22, who was also cognitively intact and had an indwelling urinary catheter, was under a urology consult that required notification of the urologist if UTI symptoms developed. The resident exhibited symptoms such as lower back pain and urinary frequency, leading to the reinsertion of the foley catheter. However, there was no documented evidence that the urologist was notified about these symptoms. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure in communication and notification protocols.
Failure to Develop Care Plan for PICC Line and IV Antibiotics
Penalty
Summary
The facility failed to develop a care plan for a resident who required treatment for an infection using a Peripherally Inserted Central Line (PICC) for intravenous antibiotics. The resident was admitted from the hospital for further care of a left heel wound and had physician's orders to receive 1 gram of Ertapenem daily through the PICC line. However, there was no documented evidence in the resident's clinical record indicating that a care plan was developed for the care and treatment of the PICC line, infection, or IV antibiotics. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for a resident with heart failure and high blood pressure, identified as Resident 16. The resident's care plan included specific instructions for administering Carvedilol and Lisinopril based on the resident's apical pulse. On multiple occasions in January, February, and March 2025, the facility did not adhere to these orders. Specifically, on January 6, 2025, Carvedilol was administered without obtaining the required apical pulse, which should have been held if the pulse was below 50 bpm. Additionally, Lisinopril was inappropriately withheld on January 22 and 30, and February 13 and 23, 2025, despite orders to administer it daily. On March 23, 2025, Carvedilol was withheld when the resident's apical pulse was 71 bpm, contrary to the physician's orders. The Director of Nursing confirmed these discrepancies during an interview on April 3, 2025.
Failure to Provide Privacy Cover for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide a privacy cover for a resident with an indwelling urinary catheter, as required by their policy. The policy, dated January 22, 2025, mandates that indwelling urinary catheters must be covered and placed below the bladder for proper drainage. The resident, who was cognitively intact, had an indwelling urinary catheter due to neurogenic bladder, a condition causing loss of bladder control. Observations on March 31, 2025, revealed that the resident's catheter collection bag was uncovered, and urine was visible while being transported by a nurse aide. The nurse aide confirmed the absence of a privacy bag and mentioned searching for one since the morning. The Director of Nursing also confirmed that the catheter tubing should not have been in contact with the fall mat. This deficiency was identified during a review of facility policies, clinical records, observations, and staff interviews, highlighting a failure to adhere to the facility's catheter care policy.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medication appropriately for one of the residents, identified as Resident 23. According to the facility's policy on medication storage, medications for internal use should be stored in medication carts or other designated areas. However, during an observation and interview with Resident 23, a round pink/orange pill was found on the floor in her bathroom. The resident, who was cognitively intact and required assistance for daily care needs, was receiving antipsychotic medication, specifically 25 mg of Seroquel daily for psychosis. The pill on the floor was identified as Seroquel, which the resident was scheduled to receive in the evening. Licensed Practical Nurse 2 confirmed that the medication should not have been on the floor and explained that Resident 23 was the only one using that toilet, and her morning medications were crushed and served with pudding or applesauce. The Director of Nursing also confirmed that medication should not be on the floor, indicating a failure in adhering to the facility's medication storage policy. This incident highlights a deficiency in the facility's handling and storage of medications, as outlined by the relevant state codes.
Failure to Administer Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and/or received necessary vaccinations, specifically the pneumococcal and influenza vaccines. Resident 5, who was cognitively intact, had consented to receive the pneumococcal vaccine as indicated by a signed authorization form dated November 19, 2024. However, the resident did not receive the vaccine, which was confirmed by the Registered Nurse Assessment Coordinator. Similarly, Resident 11, also cognitively intact, had consented to receive the influenza vaccine as per a consent form dated October 2, 2024, but did not receive it, as confirmed by the Director of Nursing. Additionally, Resident 14, who was cognitively intact and dependent on staff for daily care, was not documented as having been offered the influenza vaccine for the 2024-2025 flu season. The Director of Nursing confirmed the absence of documentation indicating that the resident was offered the vaccine. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews, highlighting a failure in the facility's vaccination procedures.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a maintenance worker and a resident with severe cognitive impairment and vascular dementia. The resident, who was rarely understood and sometimes able to understand others, was observed by two nurse aides to be inappropriately touched by the maintenance worker. Specifically, the maintenance worker was seen straddling the resident while she was seated in her recliner, hugging her, and rubbing her flank area under her shirt. One of the nurse aides recorded a video of the incident on her personal cell phone to document the behavior, as she believed it might not be believed otherwise. Interview statements from the involved staff confirmed the observations, with one aide stating that the maintenance worker's hand was under the resident's shirt and that he was rubbing her side. The maintenance worker admitted to hugging the resident but could not recall if his hand was under her shirt. The incident was witnessed by two nurse aides, who corroborated each other's accounts. The facility's abuse policy required that residents be protected from all forms of abuse, including sexual abuse, but this policy was not upheld in this instance.
Resident Recorded Without Consent During Incident Involving Staff
Penalty
Summary
The facility failed to ensure that residents were protected from being recorded on a personal cell phone without their permission. Facility policy stated that residents should be provided with a safe environment free from abuse, mistreatment, neglect, exploitation, and misappropriation of property. In this incident, a resident with severe cognitive impairment and vascular dementia, who was rarely understood and sometimes able to understand others, was involved. Maintenance staff was observed by two nurse aides to be straddling the resident while she was seated, hugging her, and rubbing her flank area under her shirt. One of the nurse aides, after observing this behavior, used her personal cell phone to record a video of the interaction without the resident's consent. Interview statements revealed that the nurse aide recorded the video because she believed the situation was unusual and wanted evidence of what she witnessed. The resident's face was not visible in the video, and the resident could not be identified. The Nursing Home Administrator confirmed that staff were not permitted to use personal cell phones during working hours and acknowledged that the nurse aide was aware she should not have recorded the video. The incident was determined to be a failure to protect the resident's rights and privacy as outlined in facility policy and state regulations.
Incomplete Documentation of Resident Assessments
Penalty
Summary
Westminster Woods at Huntingdon was found to be non-compliant with federal and state regulations regarding the maintenance and documentation of resident medical records. The facility failed to ensure that clinical records were complete and accurately documented for a resident who was cognitively impaired and had a history of stroke. On January 18, 2025, the resident was found on the floor, and although neurological checks were ordered, there was no documented evidence of registered nurse assessments at critical times when the resident's condition changed, such as when the resident complained of a dry mouth, had issues answering questions, and could no longer raise her arm. The facility's policy required documentation of all assessments and interventions following an incident, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that the assessments were completed but not documented in the clinical record, which was a requirement. This lack of documentation was a violation of both federal regulations under 42 CFR Part 483 and state regulations under 28 PA Code, which mandate that medical records be complete, accurately documented, and systematically organized.
Plan Of Correction
Resident 1 Electronic Medical Record was updated to reflect nurse assessments in the clinical record. A review of current residents reported change in conditions that occurred in the last 30 days will be completed to ensure there is a documented nurse assessment in the clinical record. Education provided by Director of Nursing to current licensed staff the process to record nurse assessment in medical record after evaluation. Director of Nursing or designee will audit 3 random resident records for change in condition x 4wks, then 3 random records monthly for documentation of nursing assessment when appropriate. These audits will be forwarded to Quality Assurance for review.
Failure to Notify Department of Health of Incident
Penalty
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for serious harm. The resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Following this incident, neurological checks were initiated. Later, the resident's daughter requested that the resident be sent to the emergency room for evaluation, and the resident was subsequently admitted to the hospital with a diagnosis of a stroke. Despite these events, there was no documented evidence that the incident was reported to the Department of Health until after Adult Protective Services contacted the facility, confirming the delay in notification.
Plan Of Correction
Resident 1 has had an incident reported to the Department of Health. A review of the last 30 days incidents were audited to find any resident who were sent for treatment to verify they had been reported to the Department of Health. Education provided to Director of Nursing regarding the process to report resident admissions to the hospital when they are due to an incident that occurred in the facility. Nursing Home Administrator or designee will audit 3 random resident incident reports for transfer to hospital x 4 weeks, then 3 random records monthly for documentation of Event Report submitted to the Department of Health when appropriate. These audits will be forwarded to Quality Assurance for review.
Failure to Develop Comprehensive Care Plan for UTI Management
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident experiencing frequent urinary tract infections (UTIs) and related medication use. The facility's policy, dated March 26, 2024, required that care plans be developed with input from an interdisciplinary team and involve the resident or their representative. However, for one resident, there was no documented evidence of a care plan addressing their frequent UTIs and the use of medications prescribed for prevention and treatment. The resident's quarterly Minimum Data Set (MDS) assessment indicated they were frequently incontinent of urine and occasionally incontinent of bowel. Physician's orders included various medications and treatments for UTI prevention and treatment, such as D-mannose, Estradiol cream, and Macrobid. Despite these orders, the facility did not create a care plan to manage the resident's condition, as confirmed by the Director of Nursing during an interview.
Failure to Complete Monthly Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication reviews were completed for two residents, as required by their policy. The policy, dated March 26, 2024, mandates that comments and recommendations from the consultant pharmacist regarding medication therapy be communicated in a timely manner, allowing for a response before the next review. If the prescriber does not respond within 30 days, the Director of Nursing or the consultant pharmacist should contact the Medical Director. However, for Residents 3 and 14, there was no documented evidence that the monthly medication reviews for December 2023 and January 2024 were addressed by the physician or designee. An interview with the Director of Nursing on May 16, 2024, confirmed the absence of documentation indicating that the medical provider addressed the medication reviews for these months. This deficiency was identified during a review of clinical records and staff interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding pharmacy services.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On May 14, 2024, a Licensed Practical Nurse (LPN) left the medication cart unattended twice without securing the computer screen, which displayed Resident 48's personal health information. The screen was facing the hallway, making the information visible to passersby. The LPN acknowledged the oversight during an interview, confirming that the information should have been covered. The Director of Nursing also confirmed that the computer screen should have been secured when unattended.
Failure to Reassess Elevated Blood Pressure
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not further assessing an elevated blood pressure for one resident. The resident, who was moderately cognitively impaired and had diagnoses including chronic kidney disease and primary hypertension, was on medication for high blood pressure. On a specific day, the resident's blood pressure was recorded at 197/86 mm/Hg, which is significantly higher than the normal range of 120/80 mm/Hg as determined by the American College of Cardiology and the American Heart Association. Despite the elevated reading, there was no documented evidence that the blood pressure was reassessed. Interviews with nursing staff confirmed that such an elevated reading would typically warrant a recheck, evaluation, and documentation, which did not occur. The Director of Nursing also confirmed that the elevated blood pressure warranted further assessment, which was not performed.
Failure to Use Leg Rests During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment for residents by not using leg rests while transporting a resident in a wheelchair. Resident 47, who is cognitively impaired and requires moderate assistance for all care, was observed being pushed in a wheelchair without leg or foot rests by Registered Nurse 4. This occurred as the resident was moved from her room to the dining room, with her feet elevated due to the absence of leg rests. Registered Nurse 4 acknowledged awareness of the requirement to use leg rests during transport. The Director of Nursing confirmed that all staff, including agency and hospice staff, are expected to use leg/footrests when transporting residents in wheelchairs.
Failure to Document Rationale for Long-term Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of psychotropic drugs. The facility policy and federal regulations require that as-needed orders for psychotropic medications be limited to 14 days unless a documented rationale is provided for extending the order. In the case of Resident 14, who was severely cognitively impaired with diagnoses of depression and dementia, there was an order for a 5 mg injection of Zyprexa to be administered daily as needed for combativeness. However, there was no documented evidence that this order was discontinued after 14 days, nor was there any documented rationale for its long-term use. The clinical records, including physician progress notes and consultant pharmacist recommendations, lacked any justification for the continued as-needed use of Zyprexa for Resident 14. The Director of Nursing confirmed that there was no documented rationale provided by the attending physician or a psychiatric consultant for the long-term use of this medication. This oversight indicates a failure to adhere to both facility policy and federal regulations, resulting in the resident receiving potentially unnecessary medication without proper documentation or justification.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper security and labeling of medications, as observed during a survey. A medication cart was found unlocked and unattended by an LPN while administering medications to a resident, which was confirmed by both the LPN and the Director of Nursing. Additionally, controlled medications were not stored in a separately locked, permanently-affixed compartment within the medication refrigerator, as required. This was confirmed by both a registered nurse and the Assistant Director of Nursing. Furthermore, the facility did not label medications with the date they were opened, as required by their policy. An opened vial of Tubersol in the main medication room refrigerator and an Insulin Lispro pen in a medication cart were not properly labeled with the date they were opened. These deficiencies were confirmed by interviews with nursing staff, including a registered nurse and the Assistant Director of Nursing.
Failure to Prevent Elopement of At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent elopement for two residents identified as at risk for elopement. Resident 1, who had a diagnosis of altered mental status and was new to the facility, was identified as an elopement risk upon admission. Despite being equipped with a Wanderguard device, Resident 1 managed to exit the facility through the front door, which was opened by a receptionist who was unaware of the resident's status. The receptionist did not hear any alarms, and the resident was later found outside and brought back into the facility without injuries. Resident 2, who had a diagnosis of dementia and was also identified as an elopement risk, managed to exit the facility during a fire alarm. The fire alarm system deactivated the door magnets, allowing the resident to walk out. The resident was found outside knocking on the door to be let back in. The Wanderguard system did not function properly during the fire alarm, and the resident was promptly assisted back inside without injuries. Interviews with staff revealed that the receptionist was not familiar with Resident 1 and did not receive a photo of him in time. Additionally, the fire alarm system's deactivation of door magnets during emergencies allowed Resident 2 to exit the building. Both incidents highlighted lapses in the facility's supervision and intervention measures to prevent elopement, despite the presence of Wanderguard devices and other security measures.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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