Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Mountain Hc during CMS and state inspections, most recent first.
The facility failed to develop and implement menus that consistently followed the diet manual and policy for the regular diet. During meal observation and menu review, milk was served in 4-oz portions instead of the required 8 oz, and bread was not consistently included on lunch and dinner menus. Interviews with the CRD, FSD, RD, and LNHA showed confusion over who approved the menus, and the RD later acknowledged the menus did not reflect the diet manual’s portions for milk and bread.
Kitchen sanitation and maintenance were not maintained in accordance with policy, with surveyors observing damaged walls, missing and damaged gaskets, broken or dirty equipment, leaking sinks, debris buildup, standing water, and improper storage of mixed beverages and other items in the walk-in refrigerator. A resident also reported receiving expired milk, and a CNA verified the expiration date. Interviews showed kitchen maintenance concerns were handled verbally, with no formal logbook or written tracking system for issues or their resolution.
Pest Control Program Not Effectively Implemented in Kitchen: Surveyors observed live bugs on a kitchen wall and floor, along with glue traps filled with bugs, uncovered food prep equipment, damaged walls, and standing water in the dish area. Staff interviews showed the pest log was not being used as intended, the DOH and FSD acknowledged an ongoing pest problem, and records reflected repeated pest treatment in the kitchen with no pest sightings documented by staff in the log.
A resident with severe cognitive impairment and total ADL dependence was observed over multiple days with a dresser that had a broken drawer and nails sticking out from the inside. Staff stated disrepair items should be entered in the maintenance logbook, but the issue was not documented there. The MD and LNHA acknowledged the drawer should have been noticed and addressed right away.
Air Mattress Setting Not Matched to Resident Weight: A resident with CHF, PVD, impaired mobility, incontinence, and skin impairment history had an air mattress ordered for pressure prevention, but surveyors observed the pump repeatedly set at approximately 360 rather than being adjusted to the resident’s 259-lb weight. Staff confirmed the setting, stated they were checking that the mattress was working rather than verifying the setting, and the DON said the facility had no policy on air mattress settings.
A resident with HTN and hypertensive heart disease received several scheduled meds, including metoprolol, hydralazine, and Norvasc, that had BP/HR hold parameters. During the med pass, an RN took vitals but did not enter them into the e-MAR, and the record showed no BP/SBP documentation or plotting of BP and HR for the parameter-based orders. The RN acknowledged the e-MAR had no place to document the vitals for those meds.
Medication administration errors exceeded the 5% threshold during an observed med pass, with two errors in 27 opportunities. An LPN gave potassium chloride without reading the full e-MAR directions and administered it undiluted instead of with the required fluid, and an RN selected chewable aspirin instead of the ordered EC aspirin for a resident with HTN, AFib, and dysphagia. The observed error rate was 7.41%.
An RN and LPN were observed preparing medications for a resident, including blood pressure medications, Aspirin EC, and Apixaban, when the RN left the medication cart unlocked and entered the resident’s room. The surveyor stopped the administration just before the medications were given because the RN was about to administer the wrong form of aspirin, and the RN acknowledged the cart had not been locked.
An RN failed to perform hand hygiene and did not disinfect a BP monitor between resident contacts during med pass. The RN used the same monitor for one resident and then brought it into another resident’s room, handled the resident’s bed remote and pillows, and signed the e-MAR without observed hand hygiene. The RN later washed her hands for only 5 seconds, despite facility policy requiring at least 20 seconds.
The facility failed to ensure proper labeling and dating of food items, maintain a clean kitchen environment, and enforce hand hygiene practices. Observations revealed unlabeled food in refrigeration units, unsanitary kitchen equipment, and staff neglecting hand hygiene before food handling.
The facility did not follow its abuse policy by failing to complete reference checks for ten newly hired staff members. A review of employee files showed missing previous employer references, with some files containing undated or personal references. Interviews with facility leadership revealed inconsistencies in the hiring process, contradicting the facility's policy that mandates reference checks to screen for potential abuse or neglect risks.
The facility failed to ensure consistent physician visits for residents, with gaps in face-to-face visits and progress notes. Residents with various medical conditions, including diabetes, heart failure, and schizophrenia, were not seen by their attending physician or NP as required. Interviews with staff confirmed the inconsistency, highlighting a failure to adhere to the facility's policy for physician visits.
The facility failed to maintain appropriate food and beverage temperatures, affecting multiple resident units. Residents reported receiving cold hot meals and warm cold items, confirmed by surveyor observations. Delays in meal service contributed to the temperature discrepancies, despite the kitchen maintaining correct temperatures.
The facility failed to adhere to infection control practices, including the use of PPE and hand hygiene. A CNA did not wear a gown when entering a resident's room on contact isolation for MRSA, and two staff members assisted a resident with a Foley catheter without gowns, despite Enhanced Barrier Precautions. Additionally, CNAs were observed washing hands for less than the recommended 20 seconds before care. These actions were contrary to the facility's policies and infection prevention standards.
The facility failed to provide adequate personal hygiene and timely assistance for residents dependent on staff for incontinence care. A resident was found with soiled briefs and reported not receiving care since the previous night. Another resident was observed wearing double briefs, contrary to policy. Additionally, a visually impaired resident with moderate cognitive impairment did not receive necessary nail care, despite expressing a desire for it.
A facility failed to consistently assess a resident's dialysis access site post-dialysis, as required by their care plan and facility policy. The resident, with end-stage renal disease and an AV fistula, did not have documented checks for bruit and thrill after dialysis sessions. Despite the care plan and physician's orders specifying these assessments every shift, records lacked evidence of compliance. Interviews confirmed the absence of documentation and the importance of monitoring the site to prevent complications.
A resident in a LTC facility received both Oxycodone and Vicodin within a minute of each other, contrary to prescribed orders. The resident, who was cognitively intact and had multiple health conditions, reported the incident. The facility's Medication Error Report indicated that the nurse failed to follow the physician's order and evaluate pain management properly, leading to the error. The nurse involved was no longer employed at the facility when the surveyor attempted an interview.
The facility's QAPI committee failed to utilize the Facility Performance Improvement Plan effectively to monitor physician visit compliance. Despite a plan to audit physician and NP progress notes every other month, the DON could not provide evidence of completed audits or progress towards compliance goals. The LNHA and RNC confirmed the lack of a monitoring system, indicating a deficiency in the facility's ability to ensure effective compliance monitoring.
The facility failed to ensure the Infection Preventionist (IP) attended four out of six QAPI meetings, as required by their policy. The IP's absence was noted in meetings held in January 2023, July 2023, October 2023, and January 2024. The LNHA, DON, and Regional Nurse Consultant could not verify the IP's attendance, despite the facility's policy mandating the IP's participation in the Performance Improvement Committee.
Menus Did Not Match Diet Manual Portions for Milk and Bread
Penalty
Summary
The facility failed to ensure that its four-week cycle menus were developed and implemented in accordance with the diet manual, policy, and nutritional standards for the regular diet. During meal observation, milk was not available on the beverage cart at lunch, creamers were offered for coffee, and the main meal did not list bread, while the alternate meal listed garlic bread. Review of the active menus and extensions showed that lunch and dinner meals were planned with 4 ounces of milk instead of the 8 ounces required by the diet manual, and only 28 of 112 meals included a bread serving. The menus also showed crackers for 26 of 28 dinner meals, but this was not reflected on the extensions or resident meal tickets. The surveyor reviewed a separate three-week cycle menu that a RD stated she had approved for nutritional adequacy, but it did not match the active menus; 61 of 84 lunch and dinner selections were different. Interviews with the CRD, FSD, RD #1, and RD #2 showed confusion over who reviewed and approved the menus, and the CRD and FSD could not produce signed menus when requested. RD #2 later stated she was the final approver and signed the menus attesting to nutritional adequacy, but she acknowledged the menus did not reflect the diet manual’s portions for milk and bread. The CRD and RD #2 stated that 4 ounces of milk was being served because residents were not drinking it and there was waste, and that bread was not consistently served to avoid heavy carbohydrate meals. They acknowledged that the diet manual called for 8 ounces of milk at each meal and a slice of bread with the regular diet sample menu, but the facility menus did not consistently follow those standards. RD #2 also provided lists of residents who disliked whole or skim milk, which accounted for 23 residents out of 189, but the lists did not include substitutions, fluid-ounce preferences, or lactose-free needs.
Kitchen sanitation, equipment maintenance, and expired milk served to a resident
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and to properly store potentially hazardous foods in a safe and sanitary environment. During kitchen tours, the surveyor observed a damaged wall with a penetration near the handwashing sink and walk-in freezer, a wood square propping up a metal rack in the middle walk-in refrigerator because of a missing rack leg, and a black milk crate on the rack containing mixed beverages, including four-ounce milks and health shakes, that had been returned to the refrigerator after tray line service. The Food Service Director stated the wood could not be cleaned and sanitized and acknowledged that the mixed beverages could become outdated if not sorted and checked for use-by dates before the next meal. Additional observations showed multiple sanitation and maintenance problems throughout the kitchen. Both walk-in refrigerator doors were missing gaskets, the dry storage shelving sat flush to the floor without the required six-inch space, and several pieces of equipment were in disrepair or not functioning, including double stacked convection ovens, a single convection oven with heavy black, brown, and reddish debris, a double stacked steamer with damaged gaskets and debris, a three-door reach-in refrigerator that had been out of service, and two warming boxes with damaged gaskets and debris. The handwashing sink faucet was leaking, the food preparation sink faucet was leaking and only provided scalding hot water, a top reach-in beverage/milk refrigerator was not working, and a ceiling vent over the ice cream freezer had fuzzy grayish brown debris hanging over clean inverted coffee mugs. The dish machine room also had missing and cracked floor tiles with standing water, wood blocks propping up equipment, and walls in disrepair with penetrations and debris buildup. The survey also identified that expired milk had been served to a resident. One resident reported receiving expired milk dated 8/17/25, and later reported receiving unopened fat free milk dated 8/21/25 at breakfast; a CNA verified the expiration date and stated the kitchen was responsible, while also acknowledging that expired milk could make a resident sick. Interviews with the FSD, DOM, LNHA, and RD showed there was no formal logbook or written system for tracking kitchen maintenance concerns, and concerns were handled verbally or at morning meetings. The DOM stated he had no written or formal way to track kitchen issues or their resolution, and the RD initially stated there was a logbook but later corrected herself and confirmed there was not one.
Pest Control Program Not Effectively Implemented in Kitchen
Penalty
Summary
The facility failed to implement an effective pest control program in the kitchen. During a kitchen tour with the Food Service Director, surveyors observed a live bug walking up a white tiled wall above a stainless-steel table that had uncovered food preparation equipment on it. In the dry storeroom, surveyors also observed two live bugs walking on the floor and two glue traps filled with bugs. The kitchen area further showed damaged walls with penetrations and standing water where multiple floor tiles were missing in the dish machine area. Interviews with facility staff showed that the pest control process was not being carried out as intended. The Director of Maintenance stated he had no involvement with pest control and that the Director of Housekeeping was responsible for overseeing the program. He acknowledged there was a pest control problem in the kitchen and said staff were supposed to note pest sightings in a logbook so the exterminator could treat targeted areas. The Director of Housekeeping stated she communicated regularly with the exterminator and acknowledged the kitchen had a pest control problem, but the kitchen pest management log sheet had no reports written by the exterminator for June through 8/19/25. She also stated kitchen staff should have been filling out the log when pests were seen, but they were not doing so. Additional interviews confirmed the ongoing issue. The Food Service Director acknowledged kitchen staff were not using the logbook to identify pest sightings for the exterminator and could not explain why the exterminator completed the staff observations column when there were no reports. The Licensed Nursing Home Administrator stated he had been aware of pests in the kitchen for a few months but thought it had been taken care of. The Registered Dietitian stated she had been made aware of the pest control problem a few weeks earlier and also identified the logbook used to document pest sightings. Facility records showed multiple pest management service reports, including treatment for roach activity in the kitchen and a later heavy treatment in the kitchen, as well as an email from the pest control company requesting an after-hours intensive cleanout for the kitchen. The facility policy required staff to document pest sightings and stated the extermination company must establish an ongoing preventative program to limit the possible return of pests.
Broken Dresser Drawer in Resident Room
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for Resident #131. During observations on 8/18/2025, 8/19/2025, and 8/20/2025, the surveyor repeatedly noted the resident's dresser had a broken 3rd drawer with nails sticking out from the inside of the drawer. The resident was observed in the day room, then in a reclining chair next to the bed, and later in a reclining chair in front of the dresser, and did not respond to the surveyor's questions on the last observation. Resident #131's record showed diagnoses including Alzheimer's Disease with late onset and Type 2 Diabetes Mellitus without complications. The MDS dated 8/5/2025 indicated a BIMS score of 00 out of 15, showing severe cognitive impairment, and that the resident was dependent for all activities of daily living. An LPN stated that disrepair items should be entered in the maintenance logbook, but the broken drawer was not listed in the logbook reviewed from 6/20/25. The Maintenance Director stated he would have expected to be called right away to fix it and that a broken drawer would be addressed by removing and replacing the dresser. The LNHA stated the broken drawer should have been noticed, especially because the nails were sticking out, and that it should have been addressed right away.
Air Mattress Setting Not Matched to Resident Weight
Penalty
Summary
The facility failed to ensure that an air mattress used for pressure prevention and treatment was accurately set in accordance with the resident’s weight for one resident reviewed for pressure ulcers. Resident #172 was admitted with diagnoses including chronic diastolic congestive heart failure and adjustment disorder with depressed mood, and the quarterly MDS dated 5/8/2025 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The care plan identified a history of refusing incontinent care and refusing to go to bed at night, and also identified risk for skin breakdown related to fragile skin, PVD, impaired mobility, incontinence, and history of skin impairment. The care plan included use of a pressure relieving cushion to the chair and a low air loss mattress to the bed. The physician’s order required an air mattress on the bed for pressure prevention with a pressure prevention check of the setting and function every shift. During observation, the surveyor saw the air mattress pump at the foot of the bed and noted the setting was approximately 360. The resident stated the pump was for the air mattress because of a wound. On a later observation, the pump was again seen set at approximately 360. The resident’s nurse stated the wound care had already been done by the wound care team. During the survey, the pump setting remained at approximately 360 even after the pump was knocked off the bed and replaced. LPN #1 and RN #1 confirmed the setting was 360, and LPN #1 stated the setting should be close to the resident’s weight. The resident’s weight was verified as 259 pounds. RN #1 stated she made sure the air mattress was working but was not checking the settings, and she acknowledged signing the TAR as completed while confirming she signed that it was working. The DON stated the purpose of the air mattress was prevention of stage 3 and 4 pressure ulcers, that maintenance set the pump using resident weights, and that nurses and unit managers were responsible for checking that the weight setting was correct. The DON also stated the facility did not have a policy on air mattress settings.
Medication Parameters Not Documented During Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and acceptable standards of practice for one resident observed during a medication pass. During observation, an RN took the resident’s vital signs, including a blood pressure of 167/59 and heart rate of 67, and then prepared five medications for administration: Metoprolol Tartrate 50 mg, Depakote 250 mg ER, Hydralazine 50 mg, Buspar 5 mg, and Norvasc 5 mg. After administration, the RN signed the e-MAR, but the surveyor did not observe the RN enter the vital signs for the medications that had parameter orders. Record review showed the resident had physician orders for Hydralazine 50 mg twice daily with a hold parameter for SBP less than 110, Metoprolol Tartrate 50 mg twice daily with hold parameters for SBP less than 90 and HR less than 60, and Norvasc 5 mg twice daily with a hold parameter for SBP less than 110 and pulse per policy. The resident’s medical history included hypertension, hypertensive heart disease without heart failure, and hypertensive urgency. The e-MAR showed administration times for these medications, but nurses were not plotting blood pressure or heart rate in the record, and the full medical record contained no documentation of the resident’s blood pressure including SBP. During interview, the RN stated she took the resident’s BP and HR and wrote them on a piece of paper, but did not enter the vitals into the electronic medical record. She acknowledged that the resident had three medications requiring parameters and that the e-MAR had no place to document the BP and HR. The facility’s medication administration policy dated 11/2024 was reviewed and did not mention parameters, but instructed staff to review the e-MAR, compare orders and labels, and call the physician or pharmacist with concerns.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure that medications were administered without error at a rate of 5% or greater. During a morning medication administration observation, surveyors observed four nurses administer medications to six residents, with 27 opportunities and two observed errors, resulting in a 7.41% medication administration error rate. The deficient practice involved two residents and two nurses during the observed medication pass. For one resident, an LPN prepared potassium chloride solution and did not click and read the full directions in the e-MAR before administration. The order required potassium chloride 20 MEQ/15 ml to be diluted with at least 90 ml of fluid and given with or after meals, but the nurse administered the medication whole and undiluted. The resident was observed eating breakfast in bed at the time of the medication pass. The resident’s record reflected diagnoses including hypertension, hypokalemia, and chronic diastolic heart failure, and the resident had mildly impaired cognition. For another resident, an RN prepared aspirin 81 mg chewable tablet even though the order was for aspirin EC 81 mg delayed-release tablet. The nurse also filled a cup with water and was about to administer the medications when the surveyor stopped the nurse before the medications were given. The resident’s record reflected diagnoses including hypertension, atrial fibrillation, and dysphagia, and the resident had mildly impaired cognition. The RN acknowledged selecting the wrong aspirin form and was unable to explain the difference between enteric-coated and chewable aspirin.
Unlocked Medication Cart During Medication Pass
Penalty
Summary
The facility failed to properly secure medications in one of four medication carts observed during a medication administration pass. During observation, an RN entered Resident #74’s room after identifying the resident and taking vital signs, and an LPN prepared five medications for the resident: Carvedilol 12.5 mg, Hydralazine 50 mg, Aspirin EC 81 mg, Norvasc 10 mg, and Apixaban 5 mg. The RN also filled a cup with approximately 120 ml of water before walking into the resident’s room without locking the medication cart, and no residents were observed in the vicinity of the cart. The surveyor stopped the RN just before the medications were administered because the RN was preparing to give the wrong form of Aspirin, non-enteric coated instead of enteric-coated. When asked, the RN stated that the medication cart was not locked and acknowledged that she should have locked it before leaving the cart and entering the resident’s room. The concern was presented to the Regional DON and LNHA, and no further information was provided.
Infection Control Lapses During Medication Pass
Penalty
Summary
The facility failed to minimize the potential spread of infection during medication administration when an RN observed on one nursing unit did not perform hand hygiene or disinfect equipment between resident contacts. During medication pass, the RN took a resident’s blood pressure with a BP monitor, placed the monitor next to the medication cart without sanitizing it, prepared the resident’s medications without observed hand hygiene, and entered the resident’s room. Inside the room, the RN used the bed remote control to raise the head of the bed and handled the resident’s pillows before administering medications. After leaving the room, the RN returned to the medication cart, again without performing hand hygiene, and signed the e-MAR. The RN then took the same BP monitor into another resident’s room without disinfecting it or performing hand hygiene, and the surveyor stopped the RN before the BP was taken. When interviewed, the RN acknowledged not performing hand hygiene or disinfecting the BP monitor and stated she should have disinfected the monitor after taking the first resident’s vitals and performed hand hygiene after administering medications. The surveyor also observed the RN wash her hands for only 5 seconds while scrubbing away from the stream of water, despite the facility policy requiring vigorous handwashing for a minimum of 20 seconds. Facility policies reviewed by the surveyor stated that hand hygiene is required before preparing medications, after resident contact, and that equipment must be cleaned and disinfected between residents.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to implement a consistent system for labeling and dating potentially hazardous foods, as observed during a kitchen tour. Various food items in the walk-in refrigeration unit, such as cabbage, celery, grapes, mushrooms, chicken, and turkey bologna, were found without use-by dates. Additionally, the refrigeration unit itself was not maintained in a clean condition, with black spots and debris observed on the fan grate, ceiling, and walls. The walk-in freezer also had issues, including a ripped door gasket and unsealed food items without use-by dates. The kitchen environment and equipment were not maintained in a clean and sanitary manner. The dry storage room contained a large unsealed bin with stains and debris, and the floor had debris in the corners. The can opener was soiled with dark debris, and a large slicer identified as clean was found with food debris upon inspection. A fan inside the kitchen was covered with dust-like debris, and the ceiling in the dry storage room had splatters of various colored debris. Staff failed to perform appropriate hand hygiene, increasing the risk of contamination. During a lunch meal observation, a staff member was seen wiping perspiration off their head with paper towels and then placing gloves on without performing hand hygiene. This staff member proceeded to plate food on uncovered dishes transported on a cart. The facility's hand hygiene policy emphasizes the importance of hand hygiene to prevent infection spread, yet it was not adhered to in this instance.
Failure to Implement Reference Check Policy for New Hires
Penalty
Summary
The facility failed to implement its abuse policy by not completing reference checks for ten newly hired staff members. The surveyor reviewed the files of ten randomly selected new employees and found that none had the required previous employee references on file. Instead, some files contained undated or personal reference letters, which were not in compliance with the facility's policy. The Human Resource Director admitted to not obtaining reference letters prior to hiring and stated that references could be from relatives or co-workers, which contradicts the facility's policy. Interviews with the Administrator, Director of Nursing, and Regional Registered Nurse revealed inconsistencies in the hiring process. The Administrator stated that references should be obtained before hiring, while the Regional Registered Nurse emphasized the importance of verifying references and contacting previous employers. The facility's policy, reviewed in November 2023, mandates reference checks, license checks, and background checks to screen prospective employees for potential risks of abuse or neglect. However, the facility did not adhere to these procedures, leading to the deficiency.
Inconsistent Physician Visits in LTC Facility
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. Additionally, residents were not consistently seen by the attending physician or Nurse Practitioner (NP) every thirty days, with a physician visit at least every sixty days. This deficiency was observed for eight residents, who were not seen by their attending physician or NP as required by the facility's policy and applicable regulations. For instance, one resident, who had been at the facility for almost two years, reported seeing the doctor only two or three times. The resident's medical records revealed multiple diagnoses, including Type 2 Diabetes Mellitus, heart failure, and dependence on renal dialysis. Despite these conditions, there were significant gaps in the physician's visits, with no progress notes from the attending physician or NP for several months. Similar patterns of missed visits and lack of documentation were observed for other residents, who had various medical conditions such as metabolic encephalopathy, hemiplegia, paranoid schizophrenia, and end-stage renal disease. Interviews with facility staff, including the Registered Nurse/Unit Manager and the Licensed Nursing Home Administrator, confirmed the inconsistency in physician visits. The facility's policy required the attending physician to visit residents at least once every thirty days for the first ninety days following admission and at least every sixty days thereafter. However, the surveyor found that the facility did not adhere to this policy, resulting in a failure to provide adequate supervision and care for the residents.
Inadequate Food Temperature Management
Penalty
Summary
The facility failed to serve food and beverages at appropriate and appetizing temperatures, affecting three of five resident units and several residents, including one specifically reviewed for food concerns. Observations and interviews revealed that residents consistently received hot food that was cold and cold food that was warm. For instance, Resident #165 reported that hot meals and coffee were cold during all three meals. During a resident council meeting, three out of five residents expressed similar concerns, with some opting for cold cereal to avoid cold hot meals. Observations by surveyors confirmed these issues, with meal trays being delivered and served at temperatures below the acceptable range. Surveyors conducted meal observations across different units, noting significant delays between the arrival of meal carts and the serving of meals, contributing to the temperature discrepancies. For example, on one unit, a meal cart arrived at 8:13 AM, but the last meal tray was not served until 8:37 AM, resulting in food temperatures well below the acceptable range. The Food Service Director confirmed that the kitchen maintained appropriate temperatures, indicating that the issue arose during the delivery and serving process. The facility's test tray form outlined acceptable temperature ranges, which were not met during the surveyor's observations.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to accepted standards of infection control practices, specifically in the use of Personal Protective Equipment (PPE) and hand hygiene. During a survey, it was observed that a Certified Nursing Assistant (CNA) did not don a gown before entering the room of a resident on contact isolation for Methicillin-resistant Staphylococcus Aureus (MRSA). The CNA acknowledged the oversight, stating that they were not informed to wear a gown when delivering meal trays. The Licensed Practical Nurse/Nurse Manager confirmed that the CNA should have donned a gown, as the resident was on contact isolation, and emphasized the importance of PPE in preventing the spread of infection. In another instance, two staff members were observed assisting a resident with a Foley catheter without wearing the required gowns, despite signage indicating the need for Enhanced Barrier Precautions. The staff members were unaware of the requirement to wear gowns during high-contact care activities, such as changing linens and dressing the resident. The Registered Nurse/Unit Manager confirmed that all staff should wear the required PPE while providing care, and the facility's policy for Enhanced Barrier Precautions was not being followed. Additionally, the surveyors noted deficiencies in hand hygiene practices. Two CNAs were observed washing their hands for less than the recommended 20 seconds before donning gloves and performing incontinence care. Interviews with the CNAs and other staff revealed inconsistencies in understanding and executing proper hand hygiene procedures. The facility's policy required vigorous hand washing for at least 20 seconds, but this was not consistently practiced by the staff.
Deficiencies in Personal Hygiene and Incontinence Care
Penalty
Summary
The facility failed to provide adequate personal hygiene and timely assistance for residents dependent on staff for incontinence care. Resident #147 was observed in bed with two adult briefs, the inner one saturated with urine and soiled with feces. The resident reported not receiving incontinence care since the previous night, despite requesting assistance from the CNA. The facility's policy indicated that incontinence rounds should occur every two hours, and residents should not be double briefed. However, documentation showed that Resident #147 had not received care since the previous evening. The resident had a history of severe cognitive impairment, incontinence, and a Stage 3 pressure ulcer, necessitating consistent care. Another resident, #21, was also found wearing two adult briefs, although they were dry at the time of observation. The resident was admitted with diagnoses including cerebral infarction and a Stage 3 pressure ulcer, and was totally dependent on staff for toileting hygiene. CNAs acknowledged making incontinence rounds twice per shift and stated they would inform a nurse if a resident was found in double briefs. However, the practice of double briefing was observed, contrary to facility policy. Additionally, Resident #280, who required assistance with ADLs due to visual impairment and moderate cognitive impairment, was observed with long, jagged fingernails coated with a black substance. Despite receiving morning care, nail care was not provided. The resident expressed a desire for nail cleaning, but the RN incorrectly documented a refusal of care. The facility's policy required assistance with hygiene for residents unable to perform ADLs independently, yet this was not adhered to in Resident #280's case.
Failure to Monitor Dialysis Access Site Post-Dialysis
Penalty
Summary
The facility failed to consistently assess a resident's dialysis access site upon their return from the dialysis clinic. This deficiency was identified for a resident who was admitted with diagnoses including end-stage renal disease, major depressive disorder, and hypertension. The resident's medical records indicated that they had an AV fistula on their left arm, which required regular monitoring for bruit and thrill to ensure proper function and detect any potential complications. Observations and interviews revealed that the facility did not document the assessment of the resident's AV fistula site post-dialysis. The Dialysis Communication Sheets and progress notes lacked entries confirming that the bruit and thrill were checked after dialysis sessions. The facility's comprehensive care plan and physician's orders specified the need for such assessments every shift, yet there was no evidence in the electronic medication administration record that these checks were performed post-dialysis. Interviews with the RN/UM and the administration team confirmed the absence of documentation and acknowledged the importance of monitoring the AV fistula site to prevent clotting. Despite reviewing the resident's records and care plan, the RN/UM could not provide additional information to demonstrate compliance with the required post-dialysis checks. The facility's policy mandated that licensed nurses assess and document the AV fistula site every shift, but this was not adhered to in practice.
Medication Administration Error with Narcotics
Penalty
Summary
The facility failed to ensure that a resident received as needed (prn) narcotic medication in accordance with the prescriber's orders and accepted professional standards. This deficiency was identified for one resident who was reviewed for medication management. The resident, who was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, orthopedic aftercare following surgical amputation, and hypertension, was cognitively intact with a BIMS score of 15 out of 15. The resident complained of receiving both Oxycodone and Vicodin 10 minutes apart, which was against the prescribed orders. A review of the resident's medical records revealed that on a specific date, the resident was administered 2 tablets of Oxycodone 5 mg for moderate pain and 1 tablet of Vicodin 5/300 mg for severe pain within a minute of each other. The facility's Medication Error Report indicated that the nurse failed to read the order correctly before administering the medication and should have waited an hour to reassess the resident's pain level before considering a different medication. The error was attributed to a failure to follow the physician's order and evaluate pain management therapy properly. The facility's policy for medication preparation and administration emphasizes verifying the right drug, dose, route, rate, time, and customer before administration. It also requires that controlled substances be documented at the time of administration. Despite these guidelines, the nurse involved in the incident did not adhere to these protocols, leading to the medication error. The surveyor attempted to interview the nurse involved, but the nurse was no longer employed at the facility. The administration team was informed of the concern, but no additional information was provided.
Deficiency in QAPI Plan Implementation for Physician Visit Compliance
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to effectively utilize the Facility Performance Improvement Plan to measure and utilize data regarding the frequency of physician visits. The deficiency was identified during a surveyor's review of the facility's QAPI Plan, which was supposed to ensure compliance with primary medical doctor (PMD) and nurse practitioner (NP) documentation. The plan included a monitoring process that required audits of physician and NP progress notes every other month for six months, with a goal of achieving 100% compliance within three months. However, during a meeting with the surveyor, the Director of Nursing (DON) was unable to provide evidence that these audits were conducted or that the results were presented at the QAPI meeting. The Licensed Nursing Home Administrator (LNHA) and the Regional Nurse Consultant (RNC) confirmed that they could not quantify the audits completed, indicating a lack of a monitoring system to demonstrate the effectiveness of the QAPI Plan. The facility's policy on Performance Improvement-QA Committee, last revised in January 2024, stated that the committee would implement quality assurance and performance improvement programs and address ongoing concerns through Performance Improvement Plans (PIP). However, the failure to provide evidence of audits and progress towards compliance goals highlighted a deficiency in the facility's ability to monitor and improve physician visit compliance effectively.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist (IP) at four out of six Quality Assurance and Performance Improvement (QAPI) meetings, as required by their policy. The surveyor's review of the facility's QAPI book revealed that the IP did not sign in as being in attendance at meetings held in January 2023, July 2023, October 2023, and January 2024. During an interview, the Licensed Nursing Home Administrator (LNHA) confirmed that the IP is a required member of the QAPI committee, which also includes the Administrator, Director of Nursing (DON), and the medical director, among others. The LNHA, along with the Director of Nursing and the Regional Nurse Consultant, reviewed the sign-in sheets and were unable to verify the IP's attendance at the specified meetings. The LNHA acknowledged that the purpose of the sign-in sheets was to maintain a record of attendance, while the Regional Nurse Consultant emphasized the importance of the IP's presence for reviewing infection control and identifying trends or outbreaks. The facility's policy, last revised in January 2024, clearly states that the Performance Improvement Committee should include the IP, highlighting the deficiency in compliance with their own procedures.
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Nursing homes near Vauxhall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winchester Gardens Health Care Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Alliance Care Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Cornell Hall Care & Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Birchwood Rehabilitation And Healthcare Center | 3.5 mi | ★★★★★ | 7 | 0 |
| Stratford Manor Rehabilitation And Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
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