Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with cancer of the esophagus/pharynx, aspiration pneumonia, respiratory failure, and a trach had an order for PRN hydromorphone via PEG for pain rated 4 to 10. MAR review showed the opioid was given many times over several months, including times when pain was documented as N/A or below the ordered range, and there was no documented evidence that non-pharmacological interventions were tried first. The DON confirmed the lack of documentation and that the med was administered outside the ordered pain scale.
Controlled substance records and MARs were not accurately reconciled for three residents. A resident with anxiety had lorazepam removed from inventory multiple times without MAR documentation, a severely cognitively impaired resident with dementia had multiple morphine removals without matching MAR entries, and another resident with brain injury and prostate cancer had oxycodone removals and administrations that did not match between the controlled substance record and MAR. The DON confirmed the discrepancies and acknowledged ineffective reconciliation procedures.
A resident with chronic respiratory failure was observed on continuous O2 orders wearing a nasal cannula connected to an empty tank, and an RN confirmed the tank was empty before replacing it. In a separate case, a cognitively intact resident with a tracheostomy had no documented MD orders for trach care and no consistent evidence that nursing staff completed trach care per policy; the resident also had a wound under the trach plate with slough, drainage, and odor.
Failure to protect a resident with severe cognitive impairment from sexual abuse by another resident. A resident with a history of entering other residents’ rooms and touching female residents was seated next to a vulnerable resident during an activity and repeatedly attempted to touch the resident’s lower body. An activity aide did not immediately intervene or separate the residents, left the unit without notifying staff, and later observed the resident with a hand down the other resident’s pants before notifying an LPN.
A resident with cardiomyopathy, cerebral infarction, CHF, and kidney failure was not given a discharge plan that reflected his goals or needs. The resident was initially cognitively intact but later had moderate cognitive impairment, and a court later appointed a guardian to decide living arrangements and care needs. The DON could not provide evidence that the facility documented discharge needs, assessed capacity for self-care, or identified the support needed for the guardian to make an informed decision about safe discharge planning.
A resident with pancreatic cancer, hemiplegia, and malnutrition had an admission MDS that did not accurately reflect hospice status. Although a physician ordered hospice services, Section O of the MDS was coded to show no special treatments or hospice care, and the RNAC acknowledged the error during interview.
Failure to develop and implement a comprehensive care plan for a resident with an implanted venous port. The resident had pancreatic cancer, hemiplegia, and moderate protein-calorie malnutrition, and a nursing note documented a port in the right upper chest. A physician order required monthly NS and heparin flushes for the non-accessed port, but the care plan did not address the device, site monitoring, or ordered maintenance.
Late Medication Administration: Two residents received scheduled meds outside the facility’s required time frame. One resident with dementia and major depressive disorder had several meds documented as given more than an hour late, and another resident with HTN and atrial fibrillation had multiple evening meds documented as given two hours late. The DON confirmed the late administration was not consistent with professional standards.
Delayed Notification of Final Urine Culture Results: A resident with anxiety disorder and HTN had a UA/C&S ordered for urinary symptoms, but the final culture later showed >100,000 colonies/mL of Enterococcus species and was not promptly reported to the ordering MD. The resident reported urinary frequency, urgency, fatigue, and concern due to a prior sepsis history from a UTI. Nursing notes showed earlier review of preliminary results, but the final abnormal result was not communicated until later, when the on-call MD was contacted and Macrobid was ordered.
Improper Storage of Bedpan and Graduate: A bedpan was observed unbagged on a bedside table next to a resident's toilet paper and telephone, and a graduate was observed on a bathroom counter next to the sink in a shared bathroom. An RN aide stated the bedpan should be bagged and stored in the cabinet under the bedside table, and another RN aide confirmed the graduate should not be placed on the counter where handwashing occurs. The DON was later interviewed regarding the improper storage of resident personal care equipment.
Failure to Confirm and Report Significant Weight Loss: A resident with Alzheimer’s disease and depression had a documented 5%+ unplanned weight loss, but the chart did not show a next-day reweight to confirm the loss or timely MD notification. The RD later noted the resident’s weight loss, questioned it, and planned fortified foods and weekly weights, but the record still lacked evidence of physician notification after the loss was confirmed.
Two residents with significant fall risks experienced repeated unwitnessed falls due to the facility's failure to conduct thorough investigations or implement individualized safety interventions. One resident with hemiplegia and cognitive impairment had ten falls with injuries, while another non-ambulatory resident with dementia suffered multiple falls, one resulting in a serious femur fracture requiring hospitalization. Staff confirmed that interventions were ineffective and not tailored to the residents' needs.
A facility failed to follow its abuse prohibition procedures after a nurse aide reported hearing inappropriate noises from a resident's room while a visitor was present. The LPN did not immediately escalate the report, resulting in delayed notification to administration, the physician, the resident's representative, and the State Survey Agency. The internal investigation was not initiated until two days after the alleged incident, and required documentation was missing from the clinical record.
A resident with severe dementia and a care plan for managing agitation and resistance did not receive the individualized, person-centered interventions outlined in their plan. During an episode of combative behavior and yelling, staff did not follow the care plan directive to stop care and re-approach later, and this was confirmed by documentation and staff interviews.
A resident with dementia and COPD did not receive a comprehensive nutritional and hydration assessment after admission, despite being prescribed Lasix. The resident had several days of low fluid intake that was not reported to nursing staff, and lab results indicated dehydration. The lack of assessment and intervention led to a hospital transfer for acute kidney injury with dehydration.
The facility failed to maintain functional battery-powered emergency lighting on the second floor. Emergency light #4, located outside the Administrator's office, had a left bulb that did not illuminate when tested. This was confirmed during an exit interview with the Facility Administrator and Maintenance Manager.
The facility failed to maintain the sprinkler system on one of the two floors, as observed in the Dietary walk-in freezer, which was missing an escutcheon. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Manager.
The facility failed to maintain proper latching of corridor doors on the second floor, affecting the Activities room and a resident's room. During an observation, it was found that these doors did not latch into their frames, compromising their ability to resist smoke passage. This deficiency was confirmed in an exit interview with the Facility Administrator and Maintenance Manager.
The facility failed to obtain physician orders for oxygen therapy and maintain oxygen and nebulizer equipment for four residents. Observations revealed undated oxygen tubing, missing or dusty concentrator filters, and outdated nebulizer equipment. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies for respiratory care.
The facility failed to submit MDS assessments to the CMS QIES ASAP system within the required 14-day timeframe for two residents. One resident's quarterly MDS assessment contained errors and was not corrected and resubmitted on time, while another resident's discharge assessment was not completed or submitted within the required period. The RNAC confirmed these deficiencies during an on-site survey.
A facility failed to accurately reflect a resident's dialysis treatment in the MDS assessment. The resident, with end-stage kidney disease, required hemodialysis thrice weekly, but the MDS incorrectly indicated no dialysis. This error was confirmed by the Nursing Home Administrator.
A facility failed to develop a baseline care plan that addressed a resident's immediate care needs upon admission. The resident, with osteomyelitis and diabetes mellitus, had a communication barrier as they did not speak English well. The care plan did not identify this barrier or include interventions to address it. The DON confirmed the plan lacked necessary information for effective communication.
A resident experienced delays in medication administration, with medications scheduled for 9:00 AM being given significantly late on multiple occasions. The resident, diagnosed with conditions such as pulmonary hypertension and osteoarthritis, reported increased pain due to the late administration of morphine. The facility's policy requires medications to be administered within one hour of their prescribed times, which was not adhered to, as confirmed by the Nursing Home Administrator.
A resident was admitted with multiple health issues, including a stage III pressure ulcer, but the RN did not document a thorough wound assessment as required. Four days later, a wound care specialist identified a stage IV ulcer. The facility failed to ensure timely assessment and documentation, as confirmed by the DON.
A resident with dysphagia and functional quadriplegia, requiring a PEG tube for nutrition, was observed lying flat during an active enteral feeding, contrary to physician orders and facility policy. This was confirmed by an LPN and the DON, highlighting a failure to adhere to care protocols designed to prevent complications.
A resident with a bimalleolar fracture did not receive effective pain management as the facility failed to document attempts of non-pharmacological interventions before administering opioid medication, contrary to its policy. The resident's medication was administered multiple times without adherence to the prescribed guidelines, as confirmed by the DON.
A facility failed to provide sufficient staff with the necessary competencies to meet the behavioral health needs of a resident with bipolar disorder, anxiety, and depression. The resident reported increased anxiety, but the nurse practitioner did not adjust medication due to insufficient documentation of symptoms. The facility's policy requires behavioral health services to be provided according to assessments and care plans, but documentation was inconsistent, with most shifts lacking anxiety behavior tracking. The DON confirmed the lack of documentation per physician orders.
The facility failed to label opened multi-dose vials with an open date and did not remove expired IV supplies from use. An opened vial of Acetylcysteine Solution 10% was found without a date, and expired IV supplies were available in the First Floor Nursing Unit. These issues were confirmed by staff interviews.
The facility failed to meet the required nurse aide to resident ratios on multiple shifts, with insufficient staffing on the day, evening, and night shifts according to the census. For example, the evening shift on one occasion had 9.1 nurse aides instead of the required 10.27 for a census of 113. The Nursing Home Administrator confirmed these deficiencies, and no additional higher-level staff were available to compensate.
The facility did not meet the required LPN to resident ratios on three shifts. On one night shift, there were 2.72 LPNs instead of the required 2.88 for 115 residents. On two day shifts, there were 3.59 and 4.19 LPNs instead of the required 4.56 and 4.52 for 114 and 113 residents, respectively. No additional higher-level staff were available to compensate for this deficiency.
The facility did not meet the required minimum of 3.2 hours of direct resident care per day, providing only 3.02 and 2.60 hours on two separate days. This was confirmed by the Nursing Home Administrator.
A facility failed to provide scheduled showers for a resident with dementia and a foot fracture, instead giving bed baths without documented reasons or refusals. The resident was supposed to receive showers twice a week, but this was not adhered to, as confirmed by the Nursing Home Administrator.
A resident with dementia and a foot fracture experienced a significant weight loss of 7.8% within eight days, which was not promptly addressed by the facility. The facility's policy required immediate verification and reporting of significant weight changes, but there was no evidence of weekly weight monitoring or timely notification to the resident's physician and representative. The resident was discharged without further documented weight monitoring.
The facility failed to meet the required nurse aide to resident ratios on multiple shifts, as confirmed by staffing records and an interview with the Nursing Home Administrator. On several occasions, the number of nurse aides was below the required levels for the day, evening, and night shifts, with no higher-level staff available to compensate for the shortfall.
The facility failed to meet the required LPN to resident ratios on nine shifts, with insufficient LPN staffing on various day, evening, and night shifts in December 2024. The facility's staffing records confirmed these deficiencies, and no additional higher-level staff were available to compensate. An interview with the Nursing Home Administrator confirmed the failure to meet the required ratios.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on several occasions in December 2024, with care hours ranging from 2.82 to 3.19. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain a safe environment by leaving medications unattended at the bedside tables of two residents without proper assessment or documentation. The residents were not evaluated for their ability to self-administer medications, contrary to facility policy, leading to potential accident hazards.
A resident with severe cognitive impairment and a history of critical illness was left unsupervised on the toilet, resulting in a fall and facial fracture. The care plan required two staff members for assistance, but one left the room, and the remaining aide left the resident alone to call for help when the resident appeared unsteady.
The facility failed to maintain a clean and orderly environment in one of its nursing halls, with observations revealing unclean conditions such as food, dirt, and debris on floors, overflowing trash cans, and maintenance issues like a broken protective grate. Interviews confirmed infrequent cleaning, and the NHA acknowledged the requirement to maintain a clean environment.
A resident with a chronic pressure ulcer did not receive prescribed treatments for 24 days due to an error in the eTAR, leading to 48 missed treatments. Upon readmission, the resident's condition worsened to a stage 3 pressure ulcer, with no documented evidence of treatment or wound tracking until assessed by a specialist.
A facility failed to prevent complications with enteral tube feedings for a resident with a PEG tube. The care plan lacked details on the tube type and size, and the facility continued administering feedings and medications through a clogged tube for three days. Staff interviews confirmed a lack of documentation on tube functionality and failure to notify the physician or resident's representative about the delay in tube replacement.
A deficiency was found when a resident with dementia and bipolar disorder was prescribed PRN Ativan .5 mg for anxiety, which did not comply with CMS guidelines for a 14-day duration limit on PRN psychotropic medications. The facility lacked documentation of the attending physician's response to the pharmacist's identified irregularity, and the DON confirmed no action was taken.
The facility failed to maintain proper storage temperatures and adhere to expiration dates in one medication storage room. The 2nd Floor Medication Room refrigerator was consistently below the acceptable temperature range, and the medication cabinet contained expired medications. The DON confirmed these deficiencies.
The facility failed to provide written notices of hospital transfers in a language and manner easily understood by residents or their representatives. Three residents were transferred for various urgent medical needs, but the notices did not use comprehensible language. The Nursing Home Administrator confirmed this deficiency.
A resident with severe cognitive impairment and a history of aggressive behavior was not adequately supervised, leading to an altercation with another resident. Despite being on one-to-one supervision, the resident was left unsupervised, resulting in physical abuse. The facility failed to follow its supervision protocol, as confirmed by the DON.
A facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and vascular dementia, who required one-to-one supervision due to aggressive and inappropriate behaviors. Despite being placed on one-to-one supervision after an incident, the care plan did not include this requirement, leading to a physical altercation with another resident. The Director of Nursing confirmed the oversight in the care plan.
A resident with a history of aspiration was served the wrong consistency diet, leading to a potential choking incident. The facility failed to investigate or document the event, revealing deficiencies in their QAPI program. Staff interviews indicated a lack of communication and awareness of the incident's severity.
The facility failed to adequately respond to and resolve resident and family complaints, including issues with cold meals, delayed call bell responses, and inadequate personal care. Specific grievances included delayed assistance with toileting, vomiting, and oxygen needs, as well as concerns about staff behavior and call bell accessibility. Management could not provide evidence of efforts to ensure resident satisfaction with the actions taken to address these complaints.
The facility failed to protect residents from being disenrolled from their Medicare Advantage Plans without informed consent, affecting nine residents. The facility did not follow CMS guidance, which requires full explanation of risks and assessment of cognitive function. Interviews revealed that staff initiated plan changes without proper documentation or resident understanding.
The facility failed to maintain a clean and orderly environment on the first floor. Observations included peeling paint on windowsills, missing and broken floor tiles, stained ceiling tiles, and soiled linens on the floor. The DON confirmed the requirement for housekeeping and maintenance services.
Pain medication given without documented pain assessment or non-pharmacological interventions
Penalty
Summary
The facility failed to provide effective pain management for a resident with diagnoses including malignant neoplasm of overlapping sites of the esophagus and pharynx, severe aspiration, aspiration pneumonia, respiratory failure, and tracheostomy. The resident had a physician order dated November 18, 2025, for Hydromorphone HCL Oral Liquid 1 mg/ml, 4 ml via PEG tube every four hours as needed for a reported pain level of 4 to 10. The facility policy on Pain Assessment and Management stated that non-pharmacological interventions may be used alone or with medications and listed examples such as repositioning, compresses, range of motion, relaxation techniques, music, and diversional activities. Review of the MAR showed licensed nurses administered Hydromorphone HCL multiple times over several months, including 27 administrations out of 78 opportunities in November 2025, 92 out of 186 in December 2025, 80 out of 186 in January 2026, 79 out of 168 in February 2026, and 68 out of 186 in March 2026. The MAR also showed several administrations when the recorded pain level was documented as N/A, and other administrations when the recorded pain level was 3, 2, 0, or 1, which was outside the ordered pain scale range of 4 to 10. The clinical record lacked documentation that non-pharmacological interventions were attempted before the opioid was given and lacked documentation that the medication was administered in accordance with the physician-ordered pain scale parameters. During interview, the DON was informed of the findings and confirmed the facility could not provide documented evidence that non-pharmacological interventions were attempted prior to administering the opioid medication. The DON also confirmed that licensed nursing staff administered Hydromorphone HCL outside of the physician-ordered pain scale for the resident.
Controlled Substance Reconciliation and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled substance medications for 3 residents. Facility policies titled Controlled Substances and Administering Medications stated that controlled medications are to be handled, documented, and administered in accordance with applicable requirements, and that the staff member administering medications initials the eMAR after giving each medication. The facility also used a controlled substance record to track and reconcile controlled medications and the MAR to document administration. Resident 6 had diagnoses including rheumatoid arthritis and generalized anxiety disorder and had an order for Ativan (lorazepam) 0.5 mg every 12 hours as needed for increased anxiety. Review of the resident’s controlled substance record and MAR showed four entries indicating lorazepam was removed from inventory, but there was no corresponding MAR documentation showing the medication was administered. The discrepancies occurred on January 30, 2026 at 9:00 AM, February 7, 2026 at 1:00 PM, February 12, 2026 at 10:25 AM, and February 17, 2026 at 12:30 PM. Resident 94 had diagnoses including dementia and major depressive disorder and was severely cognitively impaired with a BIMS score of 03. The resident had an order for morphine sulfate 20 mg/ml, 0.25 ml every two hours as needed for pain or shortness of breath. Review of the controlled substance record and March 2026 MAR showed 13 entries for morphine removed from inventory with no corresponding MAR documentation of administration. Resident 115 had diagnoses including traumatic subdural hemorrhage and malignant neoplasm of the prostate and had orders for oxycodone HCL 5 mg twice daily and an additional PRN order for chronic and breakthrough pain. Review of the records showed three entries for oxycodone removed from inventory without MAR documentation of administration, and two MAR entries documenting oxycodone administration without corresponding controlled substance record documentation of removal. The DON confirmed the discrepancies and acknowledged the facility failed to ensure effective reconciliation procedures for controlled medications.
Failure to Provide Ordered Oxygen and Consistent Tracheostomy Care
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders, facility policy, and professional standards for a resident with chronic respiratory failure who was ordered oxygen at 4 liters per minute via nasal cannula continuously. During observation, the resident was seated in a wheelchair wearing a nasal cannula connected to an oxygen tank that was empty. An RN confirmed the tank was empty and replaced it with a full tank, then assessed the resident and documented an oxygen saturation of 94 percent and a heart rate of 62 beats per minute. The RN also confirmed the resident had continuous oxygen orders and that staff should monitor oxygen tank levels. The facility also failed to ensure tracheostomy care was provided consistently for a resident with a tracheostomy related to malignant neoplasm of overlapping sites of the esophagus and pharynx. The resident’s care plan identified impaired respiratory status related to respiratory failure and the need for tracheostomy care, suctioning as ordered, and head-of-bed elevation. The resident’s MDS indicated the resident was cognitively intact and coded as receiving tracheostomy care while a resident. However, the clinical record contained no physician orders for tracheostomy care and no documented evidence that licensed nursing staff consistently performed tracheostomy care in accordance with facility policy. A nurse progress note documented that the tracheostomy site had a 4 cm by 0.3 cm Stage 3 wound under the tracheostomy plate with yellow slough, moderate greenish-brown drainage, and odor, and that the resident often positioned with chin to chest and complained of pain at times. The physician was notified and wound treatment orders were received. A later wound care note described the area under the tracheostomy plate as a radiation ulceration. During interview, the resident reported nursing staff performed tracheostomy care daily and were treating the site twice daily, but the facility could not provide documented evidence that tracheostomy care had been consistently completed according to policy or physician orders.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from resident-to-resident sexual abuse when another resident was observed with his hand down the resident’s pants in the activity room. The abused resident had Alzheimer’s disease and dementia, and a quarterly MDS dated February 24, 2026, showed a BIMS score of 2, indicating severe cognitive impairment. The other resident had moderate cognitive impairment with a BIMS score of 11 and had a documented history of entering other residents’ rooms and touching female residents. Facility records showed prior behaviors by the resident who later engaged in the incident, including being observed in a female resident’s room rubbing her arm and leg, entering other residents’ rooms, and coming out of a female resident’s room on multiple occasions. A care plan had been initiated for behaviors related to going into other residents’ rooms, with interventions including monitoring, redirection, and activities to keep the resident engaged. Despite this history, on the day of the incident the resident was seated next to the vulnerable resident during an activity and attempted to touch the resident’s lower body multiple times. The activity aide observed the inappropriate touching but did not immediately intervene, redirect, or separate the residents during the activity. After moving the vulnerable resident to another area, the aide left the unit without notifying other staff of the behavior. Upon returning, the aide observed the other resident facing the vulnerable resident in the activity room with his hand down the resident’s pants. The aide then notified an LPN, who directed her to notify the RNS and proceeded to separate the residents. The facility’s investigation documented that the vulnerable resident was unable to express feelings about the incident due to severe cognitive impairment, and the other resident later stated, “I didn’t mean no harm. I guess it was a mixed signal.”
Discharge plan did not reflect resident goals or needs
Penalty
Summary
The facility failed to develop and implement a discharge plan that accurately reflected a resident’s discharge goals and preferences for one resident reviewed. The facility policy required an interdisciplinary post-discharge plan developed with the resident and family, including where the resident planned to reside, follow-up care, available support, transition planning, and factors that could make the resident vulnerable to readmission. The policy also stated that if returning to the community was not feasible, the reason and decision-maker would be documented. Resident 26 was admitted with cardiomyopathy and cerebral infarction and was initially assessed as cognitively intact with a BIMS score of 14, later assessed with moderate cognitive impairment and a BIMS score of 11. The care plan identified the resident as a short-term care resident who would return to the community, with an intervention to provide written discharge instructions. The resident’s Kardex showed independence with bed mobility, transfers, dressing, eating, personal hygiene, and toileting, with physical help needed for bathing. A court document later stated the resident had cardiomyopathy, CHF, and kidney failure, was unable to receive and evaluate information effectively or make and communicate decisions essential to physical health and safety, and had a guardian appointed to decide living arrangements, meals, personal care, transportation, recreation, and consent for treatment. During interview, the resident said he was frustrated, upset about being in the facility, felt he was missing out on life in the community, believed he was independent and did not need nursing care, and stated the facility was not working with him on discharge planning. The DON could not provide evidence that the facility documented discharge needs, determined capacity for self-care, or identified the support needed for the guardian to make an informed decision about safe discharge planning.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to complete an accurate MDS for one of 27 residents reviewed, Resident 114. The RAI Manual requires each MDS to accurately reflect the resident’s status during the assessment reference period and to be completed with RN coordination and participation from appropriate health professionals, including direct observation of the resident and communication with direct care staff on all shifts. Resident 114 was admitted with diagnoses including pancreatic cancer, hemiplegia, and moderate protein-calorie malnutrition. The clinical record showed a physician’s order dated February 25, 2026, to admit the resident to hospice services due to pancreatic cancer. However, the admission MDS dated [DATE] was coded to show the resident did not require special treatments, procedures, or programs, and Section O0110-K1 for Hospice Care was marked as not under hospice care. The RNAC acknowledged during interview on March 29, 2026, that the admission MDS did not accurately reflect the resident’s hospice admission.
Failure to Care Plan Implanted Venous Port
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 114 to address the presence, care, monitoring, and maintenance of an implanted venous port in the right upper chest. Clinical record review showed the resident was admitted with diagnoses including pancreatic cancer, hemiplegia, and moderate protein-calorie malnutrition, and a nursing progress note documented that the resident had a port in the right upper chest. A physician order dated February 21, 2026, directed that the implanted venous port was not accessed and required monthly maintenance flushes of each lumen with 10 ml Normal Saline and 5 ml Heparin 100 units/ml. Review of the resident’s comprehensive care plan, initiated February 21, 2026, showed that the facility did not include the implanted venous port or interventions to monitor the site and ensure the ordered maintenance treatment was carried out according to the physician’s order. The DON was interviewed on March 29, 2026, regarding these findings.
Late Medication Administration
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses administered medications within the facility’s required time frame for two residents. Facility policy stated medications are to be administered in a safe and timely manner and within one hour of the prescribed time unless otherwise specified. Pennsylvania nursing standards cited in the report required RNs and LPNs to carry out nursing care actions that promote resident well-being, exercise sound judgment in nursing situations, and maintain accurate records. Resident 94 had diagnoses including dementia and major depressive disorder and was severely cognitively impaired with a BIMS score of 03. The resident was prescribed Lorazepam, Tramadol, Tylenol, and Valproic acid at scheduled times between 4:00 PM and 7:00 PM, but the MAR audit showed all four medications were documented as administered at 8:22 PM on March 23, 2026, more than one hour late. Resident 121 had diagnoses including hypertension and atrial fibrillation and was cognitively intact with a BIMS score of 15. The resident was prescribed multiple medications scheduled for 9:00 PM, including Atorvastatin, Potassium chloride, Citalopram, Flomax, Losartan, Lyrica, Ropinirole, Sotalol, and Xarelto, but the MAR audit showed all were documented as administered at 11:00 PM on March 23, 2026, two hours after the scheduled time. During interview, the DON confirmed the late medication administration was not consistent with professional standards and that medications should be received in a timely manner.
Delayed Notification of Final Urine Culture Results
Penalty
Summary
The facility failed to timely notify the physician of abnormal lab results for one resident. Resident 15 was admitted with diagnoses including anxiety disorder and hypertension, and the admission MDS showed the resident was cognitively intact with a BIMS score of 14. A physician ordered a urinalysis and urine culture and sensitivity on March 23, 2026. The final urine culture later identified abnormal findings of greater than 100,000 colonies per milliliter of Enterococcus species, but the physician was not made aware of the final result when it became available. Nursing documentation showed that on March 24, 2026, urine culture results were reviewed with the physician and no new orders were given at that time, but the final culture report did not result until March 25, 2026, at 3:22 PM. The resident reported urinary frequency and urgency, felt awful and fatigued, and stated she had a prior history of sepsis from a UTI and was worried about another serious infection. An RN confirmed the physician would not have been aware of the final culture results because they were not yet available, and later the on-call physician was notified and ordered Macrobid. The DON confirmed the resident met McGeer's criteria and that the physician should have been made aware in a timely manner of the final culture results.
Improper Storage of Bedpan and Graduate
Penalty
Summary
The facility failed to ensure an environment free from potential spread of infection and failed to properly store resident personal care equipment on the First Floor and Second Floor nursing units. The Infection Control Program Policy, last reviewed February 9, 2026, stated the program exists to assure a safe, sanitary, and comfortable environment and is designed to help prevent the development and transmission of communicable disease and infection. It also stated that personal care equipment such as bedpans and graduates may come into contact with bodily fluids and should be stored in a manner that prevents contamination of clean surfaces and reduces the risk of transmission of communicable disease. On March 28, 2026, at 11:02 AM, an observation in a resident room on the Second Floor revealed a pink bedpan placed on the bedside table next to a roll of toilet paper and a telephone. The bedpan was not enclosed in a protective plastic bag and was not stored in a designated cabinet. A second observation of the same room at 1:40 PM showed the same bedpan still unbagged on the bedside table next to the toilet paper and the resident's telephone. An RN aide stated the bedpan should be placed in a plastic bag and stored in the cabinet underneath the bedside table. Later that day, at 12:15 PM, a graduate was observed on top of the counter next to the sink in the shared bathroom for resident rooms [ROOM NUMBERS]. An RN aide confirmed the graduate should not be placed on the bathroom counter next to the sink where handwashing occurs due to risk of contamination. The DON was interviewed on March 29, 2026, regarding these findings.
Failure to Confirm and Report Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely identification, confirmation, and physician notification of a significant unplanned weight loss for one resident. The resident was admitted with diagnoses including Alzheimer's disease and depression, and the nutrition plan of care identified the resident as at risk for altered nutritional status related to dementia and weight fluctuations. The plan directed periodic weights and reporting of significant weight changes to the RD, physician, and family. The resident's quarterly MDS dated November 3, 2025, documented a BIMS score of 13, indicating no cognitive impairment. The resident's weight was documented as 115.1 lbs. on December 10, 2025, and then 109 lbs. on January 6, 2026, reflecting a 6.1 lb. loss, or 5.3 percent, within one month. The clinical record did not show that a reweight was obtained the next day to confirm the significant loss as required by facility policy. A nutrition progress note dated January 12, 2026, documented the 109 lb. weight and noted the resident historically weighed about 112 lbs., with meal intake ranging from 76 to 100 percent except for a few exceptions; the RD questioned the weight loss, requested fortified foods, and planned weekly weights. The weight record later showed 108.2 lbs. on January 14, 2026, confirming a 6 percent loss within 30 days, but the record did not show that the attending physician was notified of the significant weight loss. The DON and NHA reviewed and confirmed the findings during interview.
Failure to Investigate and Prevent Repeated Resident Falls
Penalty
Summary
The facility failed to adequately investigate resident falls and to timely develop and implement effective safety interventions for residents with a known history of falls and unsafe behaviors. For one resident with hemiplegia, legal blindness, and end-stage heart disease, the care plan identified fall risk and included general interventions such as education, keeping the environment free of clutter, and therapy evaluation. Despite these measures, the resident experienced ten falls within a one-month period, including both witnessed and unwitnessed incidents, resulting in injuries such as bruising, abrasions, and skin tears. Documentation showed the resident exhibited anxiousness, self-ambulation, aggression, and disruptive behaviors, but the facility did not identify root causes or implement enhanced supervision or individualized interventions, leading to repeated falls. Another resident with dementia, diabetes, and hypertension, who was non-ambulatory and required two staff for transfers and toileting, also experienced multiple unwitnessed falls. The care plan included general fall prevention interventions and a bariatric bed bolster overlay, but did not specify toileting frequency or address continence needs. The resident sustained four falls over a two-month period, with documentation lacking root cause analyses or individualized interventions after each incident. One of these falls resulted in a serious injury—a comminuted distal femoral fracture—requiring hospitalization and pain management. Interviews with facility staff, including the Assistant Director of Nursing and a corporate nurse consultant, confirmed that falls were not adequately investigated and that interventions were ineffective or not individualized. There was no evidence that the facility conducted thorough root cause analyses or developed and implemented specific interventions tailored to the residents' needs, resulting in repeated falls and, in one case, a serious injury.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to fully implement its abuse prohibition procedures in response to an alleged incident of sexual abuse involving a resident and the resident's visitor. According to the facility's abuse policy, all allegations of abuse must be reported immediately to the Director of Nursing (DON) or, in their absence, to the Nurse Supervisor on duty, with further immediate notification to the Nursing Home Administrator (NHA) and DON, including after-hours contact if necessary. The policy also requires prompt reporting to the State Survey Agency and law enforcement within specified timeframes. However, staff witness statements revealed that the initial report of the incident, which involved hearing inappropriate noises from the resident's room, was not promptly escalated according to policy. The LPN who received the report from a nurse aide did not immediately notify the RN Supervisor, and the RN Supervisor was not informed until two days after the alleged incident. There was no documentation in the resident's clinical record regarding the alleged abuse, and neither the NHA, DON, attending physician, nor the resident's responsible party were notified at the time of the incident. The facility did not initiate an internal investigation until two days after the alleged event, and notification to the State Survey Agency was not made within the required two-hour timeframe for allegations of sexual abuse. Staff interviews confirmed that the facility's abuse prohibition procedures were not followed, resulting in delayed identification, notification, and investigation of the alleged abuse. The deficiency was cited under multiple Pennsylvania Codes related to management, resident rights, responsibility of licensee, nursing services, and resident care policies.
Failure to Implement Care-Plan Interventions for Dementia-Related Behaviors
Penalty
Summary
The facility failed to implement individualized, person-centered interventions as outlined in the care plan for a resident diagnosed with severe dementia. The resident, who was admitted with a diagnosis of dementia and assessed as severely cognitively impaired with a BIMS score of 3, had a care plan in place to address behaviors such as yelling out and resistance with care. The care plan specifically directed staff to approach the resident calmly and, if the resident became agitated, to stop the activity and re-approach later when the resident was calmer. On the evening in question, two nurse aides were providing care when the resident became combative and screamed. Another staff member reported hearing a muffled voice and suspected inappropriate staff intervention, though the facility's investigation did not substantiate abuse. Despite the lack of evidence for abuse, documentation and staff interviews confirmed that the care-planned dementia interventions were not implemented during the incident. There was no evidence that staff stopped care and re-approached the resident as directed by the care plan when the resident became agitated. The Assistant Director of Nursing and the Corporate Nurse Consultant both confirmed that the individualized interventions for dementia-related behaviors were not followed for this resident.
Failure to Assess and Address Resident's Nutrition and Hydration Needs
Penalty
Summary
The facility failed to evaluate and address the nutrition and hydration requirements for one resident, resulting in a deficiency. Despite facility policies requiring comprehensive nutritional and hydration assessments by the dietitian upon admission and as needed, there was no documented evidence that such an assessment was completed for the resident after admission. The resident, who had diagnoses including dementia and COPD, was prescribed Lasix, a diuretic known to increase the risk of dehydration. The resident's fluid intake was significantly below recommended levels for several days, with recorded intakes of 240 cc, 660 cc, and 600 cc over three consecutive days. There was no documentation that nursing aides notified nursing staff of the low fluid intake, as required by policy. Laboratory results during this period showed elevated BUN and creatinine levels, which can indicate dehydration. Despite these findings and the resident's ongoing use of Lasix, there was no evidence of intake and output monitoring or nutritional interventions being established. The resident experienced a change in mental status, leading to a hospital transfer where a diagnosis of acute kidney injury with dehydration was made, and Lasix was held while IV fluids were initiated. The Director of Nursing confirmed that a comprehensive nutritional and hydration assessment was not completed and that appropriate interventions were not implemented.
Emergency Lighting Deficiency
Penalty
Summary
The facility failed to maintain functional battery-powered emergency lighting on the second floor. During an observation on April 21, 2025, at 11:15 am, it was noted that emergency light #4, located outside the Administrator's office, had a left bulb that did not illuminate when tested. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Manager on the same day at 12:30 pm.
Plan Of Correction
1) Bulb was replaced and light works as designed. 2) To identify other areas of potential concern, NHA/ designee quality monitored emergency lights. No issues noted. 3) To prevent this from recurring, NHA/designee re-educated Maintenance on scheduled emergency lighting testing. 4) To monitor and maintain compliance, NHA/designee to quality monitor emergency lighting function 1x weekly x 4 weeks then 2x monthly x 1 month. Findings will be forwarded to QA Committee for review and recommendation.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in one location, specifically on one of the two floors. During an observation on April 21, 2025, at 11:19 am, it was noted that the Dietary walk-in freezer was missing an escutcheon. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Manager on the same day at 12:30 pm.
Plan Of Correction
1) Escutcheon in walk-in freezer was replaced. 2) To identify other areas for potential concern, Maintenance Director/ designee quality monitored sprinklers within facility for escutcheon plates. Negative findings addressed. 3) To prevent this from recurring, NHA/ designee re-educated Maintenance on sprinkler escutcheon plates. 4) To monitor and maintain compliance, Maintenance Director/ designee to quality monitor sprinkler escutcheon plates 1x weekly x 4 weeks then 2x monthly x 1 month. Findings will be forwarded to QA Committee for review and recommendation.
Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to maintain proper corridor door functionality in two specific locations on the second floor, which affected the safety measures required for smoke and fire resistance. During an observation conducted on April 21, 2025, it was noted that the door to the Activities room did not latch into the frame when tested. This failure to latch compromises the door's ability to resist the passage of smoke, which is a critical safety requirement in fully sprinklered smoke compartments. Additionally, the door to Resident room 223 also failed to latch into the frame when tested. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Manager. The inability of these doors to latch properly indicates a lapse in maintaining the required safety standards for corridor openings, which are essential for ensuring the safety and protection of residents and staff in the event of a fire or smoke emergency.
Plan Of Correction
1) 2nd floor Activities Door and Room 223 were fixed by Maintenance. 2) To identify other areas for potential concern, Maintenance Director/ designee quality monitored facility doors to ensure doors latched appropriately. Negative findings addressed. 3) To prevent this from recurring, NHA/designee re-educated Maintenance on corridor opening deficiencies. 4) To monitor and maintain compliance, Maintenance Director/ designee to quality monitor facility doors for opening deficiencies 1x weekly x 4 weeks then 2x monthly x 1 month. Findings will be forwarded to QA Committee for review and recommendation.
Deficiencies in Oxygen and Nebulizer Equipment Maintenance
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy and did not maintain oxygen equipment in a functional and sanitary manner for four residents. Resident 56, who was admitted with pulmonary hypertension and obstructive sleep apnea, had a physician's order for oxygen therapy at 3.0 liters per minute. However, observations revealed that the oxygen tubing was not dated, and the oxygen concentrator filter was missing. Employee 2 confirmed these findings during an interview. Similarly, Resident 68, diagnosed with chronic obstructive pulmonary disease and respiratory failure with hypoxia, had a dusty oxygen concentrator filter, which was confirmed by Employee 3. Resident 6, with chronic obstructive pulmonary disease and cor pulmonale, was observed with a dusty oxygen concentrator filter and lacked a current physician's order for supplemental oxygen. Employee 1 confirmed the absence of a physician's order, despite the resident receiving oxygen therapy since March. The Director of Nursing acknowledged the facility's failure to obtain a physician's order for oxygen and maintain the oxygen concentrators according to facility policy. Resident 60, admitted with respiratory failure, had a physician's order for Albuterol Sulfate Nebulizer solution. However, the nebulizer mask and tubing were dated January 2, 2025, and had not been replaced as per facility policy, which requires changing every seven days. Employee 4 and the Director of Nursing confirmed the outdated nebulizer equipment, indicating a failure to maintain the resident's nebulizer equipment according to the facility's infection prevention policy.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within the required 14-day timeframe for two residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, federally mandated MDS assessments must be submitted within 14 calendar days after the MDS Completion Date. However, the facility did not comply with this requirement for Residents 41 and 45. Resident 41 had a quarterly MDS assessment with an Assessment Reference Date of January 2, 2024, which was submitted with errors in Section A (Identification Information) and Section C (Cognitive Patterns) and was not corrected and resubmitted within the required timeframe. Resident 45 was admitted and later discharged from the facility, with a Discharge - Return Not Anticipated MDS assessment scheduled but not completed or submitted within 14 days of the MDS Completion Date. The MDS for Resident 45 remained unsubmitted until it was identified during an on-site survey. The facility's Registered Nurse Assessment Coordinator confirmed the failure to submit the MDS assessments within the required timeframe.
Inaccurate MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, identified as Resident 49. The resident was admitted with end-stage kidney disease and required hemodialysis three times per week. However, the quarterly MDS assessment incorrectly indicated that the resident was not receiving dialysis treatments. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident attended dialysis three times per week and that the MDS was inaccurately coded.
Failure to Address Communication Needs in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that addressed the immediate care and safety needs of a resident upon admission. The resident, who was admitted with osteomyelitis and diabetes mellitus, had a communication barrier as they did not speak English well. The baseline care plan did not identify English as a second language or include measurable goals, objectives, or interventions to address this communication barrier. During an interview, the Director of Nursing confirmed that the baseline care plan lacked necessary information to ensure effective communication and meet the resident's immediate care needs.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring timely administration of medications for a resident. According to the Pennsylvania Code and the facility's policy, medications should be administered within one hour of their prescribed times. However, a review of Resident 56's Medication Administration Record revealed that medications scheduled for 9:00 AM were administered significantly late on multiple occasions. Specifically, on March 23, 2025, the medications were given at 10:35 AM, and on March 24, 2025, at 10:58 AM, both times exceeding the one-hour window. Resident 56, who was admitted with diagnoses including pulmonary hypertension, heart failure, and osteoarthritis, expressed frustration over the delays, particularly with the late administration of morphine, which resulted in increased pain and discomfort. The Nursing Home Administrator confirmed that medications should be administered timely in accordance with physician orders and professional standards of practice, highlighting a deficiency in the facility's adherence to these standards.
Failure to Conduct Timely Pressure Ulcer Assessment
Penalty
Summary
The facility failed to ensure a timely and thorough assessment of pressure ulcers upon admission for one resident. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the bladder, malnutrition, and abscesses, was found to have a stage III pressure ulcer on the sacrum. However, the RN responsible for the admission did not document a comprehensive wound assessment, including specific measurements and a detailed description of the wound, as required by facility policy. Four days after admission, a contracted wound care specialist identified a stage IV pressure ulcer on the resident, which had progressed to full-thickness tissue loss with exposed bone, tendon, or muscle. The wound was measured at 5.0 cm in length, 3.0 cm in width, and 0.5 cm in depth, with a calculated area of 15 square centimeters. The facility lacked documentation to show that a timely and thorough assessment was conducted by an RN upon admission. Interviews with the Director of Nursing confirmed that the facility's expectation was for an RN to complete a thorough wound assessment upon admission, including measurements and wound description, to be documented in the resident's clinical record. The facility acknowledged the failure to meet this expectation, resulting in a deficiency in resident care policies and nursing services as per state regulations.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate care and services to prevent potential complications associated with tube feedings for a resident receiving enteral feeding. The facility's policy on enteral feedings required that the head of the bed be elevated at least 30 degrees during feeding and for a specified time afterward to prevent aspiration. However, during an observation, it was noted that the resident's head of the bed was not elevated while the enteral tube feeding was actively infusing, contrary to the care plan and physician's orders. The resident involved had a medical history of dysphagia and functional quadriplegia, necessitating the use of a PEG tube for nutrition. Despite clear physician orders and care plan interventions to maintain the head of the bed elevation during and after feeding, the resident was found lying flat on their back during an active feeding session. This oversight was confirmed by both a licensed practical nurse and the Director of Nursing, indicating a lapse in adherence to the facility's policy and physician directives, potentially compromising the resident's safety.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide effective pain management for Resident 114, who was admitted with a displaced bimalleolar fracture and a history of repeated falls. The facility's policy on pain assessment and management, last reviewed on March 3, 2025, emphasized the use of non-pharmacological interventions either alone or in conjunction with medications to manage pain. However, the facility did not adhere to this policy, as there was no documented evidence of attempts to use non-pharmacological interventions before administering opioid pain medication to the resident. Resident 114 had physician orders for Tramadol HCl 25 mg and later 50 mg to be administered every 4 hours as needed for moderate to severe pain. Despite these orders, the medication was administered multiple times without any documented attempts of non-pharmacological interventions. This occurred on numerous occasions from February 25, 2025, through March 31, 2025, with pain levels reported between 4 and 8. The facility's failure to document attempts of non-pharmacological interventions before administering the medication was confirmed by the Director of Nursing during an interview on April 4, 2025. The deficiency was identified through a review of the resident's clinical records and medication administration records (MAR), which showed repeated instances of opioid administration without adherence to the facility's pain management policy. This lack of documentation and adherence to policy indicates a failure in providing comprehensive pain management for Resident 114, as required by the facility's own guidelines and state regulations.
Inadequate Staff Competency in Behavioral Health Documentation
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to meet the behavioral health needs of its residents, as evidenced by the case of one resident. This resident, who was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and depression, reported increased anxiety over several weeks. Despite the resident's reports, the nurse practitioner did not adjust the anti-anxiety medication due to a lack of documented symptoms in the nursing records. The facility's policy requires behavioral health services to be provided in accordance with comprehensive assessments and care plans, but the documentation did not reflect the resident's increased anxiety symptoms. The resident's clinical records showed that anxiety behavior tracking was inconsistently documented in the Medication Administration Record (MAR) and progress notes. For the month of March, the majority of shifts lacked documentation of anxiety behavior tracking, with only 11 incidences recorded in the MAR and 5 additional shifts noted in progress notes. A psychiatry note indicated the resident's anxiety was affecting sleep, yet staff documentation did not reflect these symptoms. An interview with the Director of Nursing confirmed the lack of documentation per physician orders, highlighting the facility's failure to employ staff with the necessary competencies to ensure resident safety and well-being.
Medication and IV Supply Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and manufacturer recommendations for the storage and labeling of medications and biologicals. Specifically, the facility did not label opened multi-dose medication vials with an open date, as observed with a vial of Acetylcysteine Solution 10% in the medication refrigerator on the First Floor Nursing Unit. This vial was opened but not dated, contrary to the manufacturer's instructions that require the solution to be discarded after 96 hours of opening. This oversight was confirmed by both an LPN and the Director of Nursing during interviews. Additionally, the facility did not ensure that expired intravenous (IV) supplies were removed from availability for resident use. During an inspection of the medication room on the First Floor Nursing Unit, expired IV supplies, including two Intravenous Winged Infusion Sets and one BD Safety IV Catheter Insertion Kit, were found. The expiration dates on these supplies had passed, and their presence was confirmed by the Director of Nursing. These findings indicate a failure to comply with the facility's Medication Storage and Labeling policy and relevant state regulations.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of twenty-one reviewed shifts. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts according to the census on several dates in January 2025. For instance, on January 23, 2025, the evening shift had 9.1 nurse aides instead of the required 10.27 for a census of 113. Similarly, on January 24, 2025, the day shift had 10.73 nurse aides instead of the required 11.40 for a census of 114. These staffing deficiencies were confirmed during an interview with the Nursing Home Administrator on January 30, 2025, who acknowledged the facility's failure to meet the required nurse aide to resident ratios on the specified dates. No additional higher-level staff were available to compensate for these deficiencies.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing or Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Incentives will be put in place for staff to pick up shifts, not call out, and assist with recruiting efforts. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee, and changes will be made as necessary.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three specific shifts out of 21 reviewed. On January 25, 2025, the night shift had only 2.72 LPNs instead of the required 2.88 for a census of 115 residents. On January 26, 2025, the day shift had 3.59 LPNs instead of the required 4.56 for a census of 114 residents. On January 27, 2025, the day shift had 4.19 LPNs instead of the required 4.52 for a census of 113 residents. There were no additional higher-level staff available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. Facility cannot retroactively correct LPN staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if LPN ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts. 4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct resident care per resident per day. On January 25, 2025, the facility provided only 3.02 hours, and on January 26, 2025, it provided 2.60 hours of direct care nursing per resident. This deficiency was identified through a review of the facility's staffing levels and was confirmed during an interview with the Nursing Home Administrator on January 30, 2025.
Plan Of Correction
1. Facility cannot retroactively correct the overall PPD. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if the overall PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper staffing PPD. The facility will hold labor meetings Monday-Friday to verify PPD is met. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts. 4. Director of Nursing/Designee will conduct random audits of overall PPD then monthly for two months thereafter to verify proper PPD. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a dependent resident, identified as Resident CR1, who was admitted with diagnoses including dementia and a fracture of the right foot. The resident was scheduled to receive showers on Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift. However, from November 26, 2024, to December 16, 2024, the resident only received bed baths on the scheduled shower days, with no documented evidence of refusals or reasons for not providing showers as scheduled. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 2, 2025, acknowledging the failure to meet the resident's personal hygiene needs and preferences.
Plan Of Correction
Step 1: Resident CR1 was discharged from the facility on 12/16/2024. Step 2: Current residents have been reviewed to ensure bathing preference is accurate and is documented as being provided per schedule. Step 3: The DON/Designee will educate certified nursing assistants to the facility process for providing and documenting resident bathing as scheduled. Step 4: The IDT will complete random audits weekly x 4 weeks then monthly x 2 months to ensure bathing is being completed per the resident preference and schedule. Trends will be reviewed by the QAPI committee for follow-up as needed.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to timely monitor the nutritional parameters of a resident who experienced a significant weight loss. According to the facility's Weight Assessment and Intervention Policy, residents should be monitored for undesirable weight changes, and any significant weight loss should be verified and reported to the dietitian immediately. In this case, a resident admitted with dementia and a foot fracture experienced a 7.8% weight loss within eight days, which was not promptly addressed. The dietitian's note, dated nine days after the weight loss, questioned the initial weight's validity and suggested the weight loss might be related to the resident's adjustment to the facility and recent hospitalization. Despite the policy requiring weekly weight monitoring after a significant weight change, there was no documented evidence of weekly weights being obtained following the initial weight loss. Additionally, the resident's physician and representative were not timely notified of the significant weight loss. The resident was discharged from the facility without further documented weight monitoring, indicating a lapse in adherence to the facility's policy and procedures for managing significant weight changes.
Plan Of Correction
Step 1: Resident CR1 was discharged from the facility on 12/16/25. Step 2: Current residents newly admitted/readmitted to the facility, since 12/01/2024 have been reviewed to ensure weekly weights have been obtained as ordered. Any resident evaluated as having a weight change has been reviewed by the Registered dietician for applicable follow-up and notification to the physician and resident representative. Step 3: The Registered dietician and Clinical Administrative team have been re-educated by the RDCO-Clinical nurse to the facility process for monitoring of resident weights and applicable follow-up for those residents identified as having a weight change. Step 4: The Registered Dietician/Designee will complete random audits weekly x 4 weeks then monthly x 2 months to ensure residents weights are being obtained as ordered and that applicable follow-up for weight changes is being completed. Audits will be reviewed by the QA Committee for further follow-up as needed.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on 14 out of 57 shifts reviewed. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts according to the census on several dates in December 2024. For instance, on December 14, 2024, the day shift had 8.80 nurse aides instead of the required 10.5 for a census of 105, and the night shift had 6.00 nurse aides instead of the required 7.00. Similar deficiencies were noted on other dates, with the facility consistently falling short of the required staffing levels. The deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing shortfall, further exacerbating the issue.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing or Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 5. Date of compliance is January 21, 2025.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on nine shifts out of 57 reviewed. Specifically, the facility did not provide the minimum LPN staffing levels on various dates in December 2024. On December 14, 15, 21, and 25, the day shift was understaffed, with fewer LPNs than required for the resident census. The evening shift on December 24 and the night shifts on December 20, 25, 27, and 28 also had insufficient LPN staffing. The facility's staffing records confirmed these deficiencies, and no additional higher-level staff were available to compensate for the shortfall. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. Facility cannot retroactively correct LPN staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if LPN ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 5. Date of compliance will be January 21, 2025.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct nursing care per resident per day, as mandated by state regulation effective July 1, 2024. A review of the facility's staffing levels revealed multiple instances in December 2024 where the nursing care hours fell short of the required minimum. Specifically, on December 14, 15, 19, 20, 23, 24, 25, 27, 28, and 31, the facility provided between 2.82 and 3.19 hours of direct care per resident, which is below the mandated threshold. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 2, 2025.
Plan Of Correction
1. Facility cannot retroactively correct the overall PPD. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if the overall PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper staffing PPD. The facility will hold labor meetings Monday-Friday to verify PPD is met. 4. Director of Nursing/Designee will conduct random audits of overall PPD then monthly for two months thereafter to verify proper PPD. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 5. Date of compliance will be January 21, 2025.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure the resident environment was free from potential accident hazards, as evidenced by the presence of medications left unattended at the bedside tables of two residents. The facility's policy on 'Self-Administration of Medications' requires that residents be assessed and deemed safe to self-administer medications, with documentation in their medical records and care plans. However, there was no documented evidence that the two residents involved were assessed or deemed safe to self-administer their medications. During observations, one resident was found with a white tablet on their bedside table while eating breakfast, and another resident had five different colored pills on their bedside table while talking on the phone. The Director of Nursing confirmed that these medications should not have been left at the bedside, as licensed nurses are responsible for administering medications. This oversight was acknowledged as an accident hazard, and the facility failed to maintain a safe environment by allowing medications to be accessible to residents without proper assessment and documentation.
Plan Of Correction
Step 1: Medications were administered by nursing. Step 2: To identify other areas for potential concern, DON/designee quality monitored resident rooms to ensure medications were not left at bedside. Negative findings addressed. Step 3: To prevent this from recurring, DON/designee educated licensed nursing staff on the Facility's medication administration policy. Step 4: To monitor and maintain ongoing compliance, DON/designee quality monitored resident rooms for medications at bedside 5x weekly x 4 weeks then 1x weekly x 4 weeks. Step 5: Findings will be forwarded to QA Committee for further review/recommendations.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement planned interventions to prevent a fall with injury for a resident who was severely cognitively impaired and required maximum assistance for activities of daily living. The resident, who had a history of critical illness myopathy, chronic respiratory failure, and Langerhans Cell Histiocytosis, was at risk for falls. The care plan required the use of a mechanical lift and assistance from two staff members for transfers and toileting. However, during an incident, the resident was left unsupervised on the toilet by one of the staff members, leading to a fall that resulted in a facial fracture. On the day of the incident, the resident was transferred to the toilet using a sit-to-stand lift by two staff members. One staff member left the bathroom, leaving the resident with only one aide, who then left the resident alone to call for help when the resident appeared unsteady. This lack of supervision resulted in the resident falling to the floor. The Director of Nursing confirmed that the staff failed to provide the proper supervision as indicated in the resident's plan of care, leading to the fall and subsequent injury.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in one of its nursing halls, specifically the first-floor nursing unit. Observations made on October 24, 2024, revealed multiple instances of unclean conditions in various rooms. These included food, dirt, and debris on the floors, sticky surfaces, overflowing trash cans, and dirty fall mats. Additionally, there were issues with maintenance, such as a broken protective grate on a heating unit and gouged walls with black marks. The tube feeding poles in some rooms had dried feeding solution on them, and overbed units were stained with food and liquid. Interviews with residents and staff confirmed the infrequency of cleaning, with one resident noting that her floor was swept and mopped "once in a blue moon." The Nursing Home Administrator acknowledged that the facility is required to maintain a clean and orderly environment to support residents' rights. The observations and interviews indicate a systemic issue with housekeeping and maintenance services, leading to the deficiency in providing a safe, clean, and homelike environment for the residents.
Failure to Administer Prescribed Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a chronic pressure ulcer on the right outer foot, as evidenced by a lack of adherence to prescribed treatment plans. The resident, who had a history of cerebral infarction, vascular dementia, congestive heart failure, and chronic pressure ulcer, was supposed to receive specific treatments for the ulcer as recommended by a podiatrist. These treatments included cleansing the area with saline, applying Betadine, and covering it with a dry sterile dressing twice daily. However, from February 13, 2024, to March 7, 2024, the facility did not administer these treatments as prescribed, resulting in 48 missed treatments over 24 days. The error was attributed to an incorrect entry in the electronic Treatment Administration Record (eTAR) by the facility's licensed nursing staff. Upon the resident's readmission to the facility after a hospital stay, further deficiencies were noted. A wound assessment conducted on March 28, 2024, revealed a blood blister on the resident's right outer foot, which later developed into a stage 3 pressure ulcer by April 15, 2024. During this period, there was no documented evidence of treatment application or weekly wound tracking by the facility. The wound care nurse confirmed the absence of documentation and treatment application until the wound care specialist's assessment. This lack of proper wound care management and documentation contributed to the worsening of the resident's condition.
Failure to Prevent Complications with Enteral Tube Feedings
Penalty
Summary
The facility failed to provide adequate care and services to prevent potential complications with enteral tube feedings for a resident with a PEG tube. The resident, who had a history of dysphagia, epilepsy, and quadriplegia, required enteral feeding through a PEG tube. The care plan for the resident did not specify the type and size of the PEG tube, nor did it include the necessary water flushes before and after medication administration. Despite a physician's order for continuous tube feeding and water flushes, the facility's documentation revealed that the resident's feeding tube was clogged, and the resident was sent out for replacement. However, the replacement did not occur due to a late arrival at the appointment, and the resident returned to the facility without the tube being replaced. The facility continued to administer medications, feedings, and water flushes through the clogged tube for three days, as indicated by the Medication Administration Records. Interviews with staff confirmed that there was no documentation to support that the tube was functioning despite being blocked, and there was no evidence that the physician or the resident's representative were informed about the delay in tube replacement. The Nursing Home Administrator and Director of Nursing acknowledged the failure to provide care and services to prevent complications associated with tube feedings and to notify the physician and resident's representative of the changes.
Failure to Address Pharmacy-Identified Medication Irregularity
Penalty
Summary
A deficiency was identified in the medication management of a resident with dementia and bipolar disorder. The resident was prescribed PRN Ativan .5 mg for anxiety, which the consultant pharmacist noted in the February 2024 monthly review. According to CMS guidelines, all PRN psychotropic medications must be limited to a 14-day duration, but the resident had an active PRN order for Lorazepam that did not comply with these regulations. The facility failed to provide written documentation of the attending physician's response to this drug irregularity, and there was no evidence that the physician acknowledged the pharmacy report. The Director of Nursing confirmed that the attending physician had not acted upon the identified pharmacy irregularity.
Improper Storage and Expired Medications in Medication Room
Penalty
Summary
The facility failed to store drugs and pharmacy supplies under proper temperatures and adhere to expiration/use by dates in one of its medication storage rooms. During an observation of the 2nd Floor Medication Storage Room, it was found that the refrigerator temperature was consistently below the acceptable range of 35 to 46 degrees Fahrenheit, registering at 28 degrees Fahrenheit. Additionally, the freezer compartment had an accumulation of ice crystals. These conditions indicate improper storage of medications and vaccines that require refrigeration. Further observations revealed that the 2nd Floor Medication Stock Medication cabinet contained outdated over-the-counter medications and supplements. Specifically, Glucosamine and Chondroitin tablets had expired in February 2024, Ferrous Gluconate tablets had a best by date of October 2022, and Sodium Bicarbonate tablets had expired in May 2024. The Director of Nursing confirmed these findings, acknowledging that the refrigerator was not within proper temperatures, the medication room was not maintained in a sanitary manner, and medications were kept beyond their expiration dates.
Failure to Provide Understandable Transfer Notices
Penalty
Summary
The facility failed to provide written notices of facility-initiated hospital transfers in a language and manner that could be easily understood by the residents or their representatives. This deficiency was identified in three out of 19 residents reviewed. Regulatory requirements mandate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Resident 32 was transferred to the hospital due to hematemesis, but the notice did not use language easily understood by the resident or their representative. Resident 56 was transferred for evaluation and treatment, and Resident 87 was transferred due to abnormal vitals, with both notices also failing to use comprehensible language. An interview with the Nursing Home Administrator confirmed the facility's failure to provide understandable transfer information.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident B2, from physical abuse by another resident, identified as Resident B1. Resident B1, who was admitted with severe cognitive impairment and a history of aggressive behaviors due to vascular dementia, was placed on one-to-one supervision following an incident of inappropriate behavior. Despite this, Resident B1 was able to physically assault Resident B2, who was moderately cognitively impaired, by grabbing and hitting him in the chest. The incident occurred when Resident B1, who was supposed to be under constant supervision, was left unsupervised at the nurses' station. The LPN on duty had left the area to attend to another resident, during which time Resident B1 approached Resident B2 and initiated the altercation. The facility's protocol for one-to-one supervision was not followed, as the staff member assigned to supervise Resident B1 did not maintain constant visual contact, allowing the incident to occur. The Director of Nursing confirmed that Resident B1 should have remained under one-to-one supervision throughout the shift, acknowledging the facility's failure to prevent the physical abuse. The facility was aware of Resident B1's aggressive tendencies but did not implement adequate supervisory measures to monitor his activities and prevent harm to other residents.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and vascular dementia. The resident, identified as having a BIMS score of 3, exhibited behaviors such as resistance to care, sexually inappropriate actions, and aggression. Despite being placed on one-to-one supervision following an incident where the resident inappropriately touched another resident, the care plan did not include this supervision requirement or criteria for re-evaluation of the supervision level. An altercation occurred when the resident, while seated at the nurse's station, engaged in aggressive behavior towards another resident, leading to a physical confrontation. The care plan, although revised, failed to address the need for continuous one-to-one supervision, which was confirmed by the Director of Nursing. This oversight in the care plan contributed to the incident and highlighted the facility's failure to implement a comprehensive plan to ensure resident safety.
Failure to Implement Effective QAPI Program Leads to Resident Choking Incident
Penalty
Summary
The facility failed to implement an ongoing Quality Assurance and Performance Improvement (QAPI) program, as evidenced by an incident involving a resident who was served the wrong consistency diet, leading to a potential choking incident. The resident, who had a history of aspiration and required a mechanically soft diet, was mistakenly given a regular consistency meal. This error was not promptly addressed or investigated by the facility, indicating a lack of effective systems for monitoring and evaluating care quality. The resident, who was moderately cognitively impaired and required assistance with daily activities, experienced a significant change in condition after consuming the incorrect meal. Staff found the resident unresponsive, pale, and foaming at the mouth, necessitating emergency medical intervention. Despite the severity of the incident, there was no evidence that the facility conducted a thorough investigation to identify the root cause or contributing factors, nor was there documentation of corrective actions taken. Interviews with staff revealed confusion and a lack of communication regarding the incident. The Director of Nursing was not informed, and the Nursing Home Administrator did not engage with the medical aspects of the situation. The facility's failure to investigate and document the incident demonstrates a deficiency in their QAPI program, as they did not ensure the quality of care and life for the resident involved.
Failure to Address Resident and Family Complaints
Penalty
Summary
The facility failed to adequately respond to and resolve resident and family complaints, as evidenced by multiple grievances and concerns that were not addressed in a timely or satisfactory manner. Residents reported issues such as cold meals, delayed response to call bells, and inadequate assistance with toileting and other personal care needs. Specific instances included a resident waiting an hour for assistance to go to the bathroom and another resident not receiving timely help with vomiting and oxygen needs. Additionally, a resident expressed concerns about a wound and rude staff behavior, which were not followed up on by the facility. Further, the facility did not provide evidence of investigating or resolving complaints about call bell accessibility and staff responsiveness. One resident's family reported that the call bell and necessary items were out of reach, and staff did not adequately address these concerns. Another resident's family reported verbal abuse and harassment by a CNA, leading to the resident being moved to a different floor. However, there was no documentation of the family's satisfaction with the resolution. Interviews with residents revealed ongoing issues with staff behavior and response times, including a resident who experienced anxiety and fear due to inadequate care and delayed assistance. The facility's management, including the Nursing Home Administrator and Director of Nursing, could not provide evidence of efforts to ensure resident satisfaction with the actions taken to address their complaints. This lack of follow-up and resolution demonstrates a significant deficiency in the facility's grievance handling process.
Failure to Protect Residents from Uninformed Medicare Advantage Disenrollment
Penalty
Summary
The facility failed to develop and implement operational policies and procedures to protect residents from being disenrolled from their Medicare Advantage Plans without their informed consent. The facility did not follow CMS guidance, which requires that residents or their representatives be fully informed of the risks and impacts of disenrollment and that their cognitive function be assessed to ensure they understand the information. This deficiency affected nine residents, who were either moderately cognitively impaired or had their responsible parties sign disenrollment forms without proper documentation of their request or understanding of the change. For example, Resident 9, who was moderately cognitively impaired, was disenrolled from his Medicare Advantage Plan without documented evidence of his request or understanding of the change. Similarly, Resident 10, also moderately cognitively impaired, was disenrolled without proper documentation or assessment of his cognitive function. In another case, Resident 11, who was cognitively intact, had his responsible party sign the disenrollment form without evidence that the resident or the responsible party initiated the request or understood the implications. Interviews with residents and their responsible parties revealed that the facility staff initiated conversations about changing Medicare plans, often presenting it as necessary for continued services. The facility did not adequately explain the risks or potential changes in coverage, benefits, and copays. The Director of Nursing confirmed that the facility lacked a policy on disenrollment and relied on CMS guidance, which was not properly followed, leading to the deficiency.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in resident areas on the first floor. Observations revealed peeling and chipped paint on windowsills at the end of each hallway, missing and peeling paint on multiple resident room doors, and missing and broken floor tiles with exposed drywall at the end of the hallway. Additionally, resident rooms had stained ceiling tiles, missing laminate on drawer surfaces, and soiled linens on the floor and draped over a wheelchair. The Director of Nursing confirmed that the facility is required to provide housekeeping and maintenance services to maintain a clean and orderly environment for its residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 455 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nanticoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewood Rehabilitation & Healthcare Center | 1.7 mi | ★★★★★ | 19 | 1 |
| Edenbrook At Hampton | 2.9 mi | ★★★★★ | 13 | 0 |
| Mountain Top Rehabilitation & Healthcare Center | 5.5 mi | ★★★★★ | 21 | 0 |
| Smith Health Care Ltd | 5.6 mi | — | 0 | 0 |
| Allied Services Meade Street Skilled Nursing | 6.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.