Birchwood Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Nanticoke, Pennsylvania.
- Location
- 395 Middle Road, Nanticoke, Pennsylvania 18634
- CMS Provider Number
- 395651
- Inspections on file
- 38
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Birchwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
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.
The facility failed to provide scheduled showers for two residents, one with mobility issues and another with muscle weakness and cirrhosis, resulting in inadequate personal hygiene services.
The facility failed to provide necessary supervision and effective safety measures for a resident at high risk for elopement and another resident at increased risk for falls. Despite having care plans in place, the facility did not adequately monitor or implement interventions, resulting in an elopement incident and multiple falls.
The facility failed to maintain proper infection control practices for a resident. Observations revealed improperly stored wound care supplies and an indwelling urinary catheter drainage bag with the drainage tube resting on the floor. The Nursing Home Administrator and DON confirmed the lapses in infection control practices.
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.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene. Specifically, the facility did not provide showers as scheduled for two residents. Resident 3, who was admitted with diagnoses requiring assistance with personal care and mobility, was supposed to receive showers on Tuesdays and Thursdays during the 7:00 AM to 3:00 PM shift. However, records show that Resident 3 was only showered once and given a bed bath twice over a two-month period, with no documented evidence of refusals or reasons for not showering the resident as scheduled. Similarly, Resident 12, admitted with diagnoses including muscle weakness and cirrhosis of the liver, was also supposed to receive showers during the 7:00 AM to 3:00 PM shift. However, the resident's bathing records for February and March 2024 revealed that the resident received only one shower each month. An interview with the Nursing Home Administrator confirmed that the facility failed to provide adequate personal hygiene services to meet the residents' needs.
Failure to Provide Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to provide necessary supervision and effective safety measures for Resident 2, who was at high risk for elopement due to dementia. Despite having a care plan that included interventions such as a wanderguard bracelet and regular checks, Resident 2 was able to exit the facility unsupervised. The incident occurred when an LPN, who was in her car, noticed the resident in a wheelchair outside the facility. The facility's investigation did not provide sufficient information on the events leading up to the elopement or staff observations prior to the incident, indicating a lapse in monitoring and supervision. Resident 3, who had severe cognitive impairment and was at moderate risk for falls, experienced multiple falls within a short period. The resident's care plan included interventions like activity programs, call lights, and safety checks, but these measures were not effectively implemented or documented. The resident had unwitnessed falls on several occasions, and the alarms meant to alert staff were either not functioning or not in place. Despite repeated falls, the facility did not timely evaluate the effectiveness of the fall prevention measures or revise the care plan to include necessary staff supervision. The facility's failure to implement effective fall and safety measures for Resident 3 resulted in repeated falls, increasing the risk of serious injuries. The documentation survey reports for January, February, and March 2024 revealed that staff were not consistently completing tasks such as checking bed and chair alarms, ensuring proper placement of fall mats, and scheduled toileting. The Director of Nursing and the Nursing Home Administrator confirmed that the facility did not provide adequate supervisory and monitoring interventions to prevent these repeated falls.
Infection Control Deficiency
Penalty
Summary
The facility failed to maintain proper infection control practices for one resident. Observations revealed several unopened sterile 4 x 4 gauze packages, an opened 1000 mL bottle of sterile water with approximately 200 mL remaining and not dated, and an uncovered 60 mL piston syringe used for irrigation on the resident's nightstand. Additionally, an opened tube of silver antibacterial wound gel was found between the foot of the mattress and the footboard of the bed. The resident's indwelling urinary catheter drainage bag was observed hanging on the side of the bed with the drainage tube resting directly on the floor. During an interview, the Nursing Home Administrator and Director of Nursing confirmed that infection control practices were not followed for the resident's wound care supplies and that the indwelling catheter was not maintained to prevent potential contamination.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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