Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgeville Rehabilitation & Care Center during CMS and state inspections, most recent first.
A facility failed to support resident choice and quality of life by not allowing residents to go outside except when family members visited and took them out. Residents with BIMS scores of 15, including those with care plans listing outdoor time as an important preference, reported repeated requests for access to fresh air and sunlight, while the NHA and DON confirmed the failure to promote resident choice.
Incomplete and inaccurate MDS assessments: The facility failed to complete required BIMS and resident mood interviews on multiple MDS assessments for 17 residents. Several residents were documented as understood or sometimes understood, yet Section C and Section D interviews were left incomplete. An LPN AC confirmed one MDS was incorrect, and the NHA and DON acknowledged the assessments were not accurate and fully completed.
Facility nursing personnel failed to maintain current CPR certification for Healthcare Providers for three of 42 licensed nurses. Review of policy showed online-only CPR was not acceptable, and the CPR cards for three LPNs showed non-healthcare provider online-only classes without a hands-on session. The NHA and DON confirmed the deficiency.
The facility failed to ensure necessary ADL care and services were provided for multiple residents with cognitive and physical impairments. Observations found residents with unkept or dirty fingernails, one resident still in a gown with long hair and beard who wanted grooming services, another resident with bed linen smeared with brown matter, and a resident reporting poor night-shift call light response; an LPN, NHA, and DON confirmed the concerns.
The facility failed to maintain documentation that 19 of 42 licensed nurses had current CPR certification to provide basic life support for a resident needing emergency care before EMS arrival and in accordance with physician orders and advance directives. The CPR policy required current healthcare-provider CPR with hands-on practice and in-person skills assessment, but certification cards were not available for multiple LPNs and RNs, and the NHA and DON confirmed the missing documentation.
Failure to maintain nutritional status and ordered supplements: Three residents had missed or incomplete nutrition interventions. One resident with CKD, CHF, and edema had inconsistent weights and later required hospital transfer for severe swelling and CHF. Another resident with DM and a stage IV pressure ulcer did not receive an ordered liquid protein supplement after hospital return, and the resident said he had not been getting it. A third resident with HTN, DM, and ESRD had missing diet orders after hospitalizations, no ST reassessment on readmission, and no active orders for ordered supplements.
Incomplete dialysis communication documentation was identified for two residents receiving scheduled HD. Facility records showed missing or incomplete pre-dialysis, dialysis center, and post-dialysis communication forms for one resident, and missing dialysis communication sheets with no related refusal or other dialysis documentation for the other resident. Both residents had ESRD, HTN, and DM, and the NHA and DON confirmed the communication failures.
Missing Physician Review of Pharmacy Recommendations: The facility failed to document physician review and signature on multiple monthly pharmacist medication regimen reviews for several residents with diagnoses including dementia, Alzheimer’s disease, diabetes, depression, falls, HTN, and insomnia. The DON confirmed the facility could not locate all past pharmacy recommendations and that the required physician signatures were missing.
Failure to Track Infections Through Required Surveillance: The facility failed to carry out required infection control surveillance to identify possible communicable diseases or infections. Review of the infection control policy showed the IP was responsible for outcome and process surveillance, but documentation for several months did not show infection tracking, and prior months were unavailable for review. The IP confirmed the facility failed to accurately track communicable diseases and infections.
Failure to implement an antibiotic stewardship program. Facility infection control surveillance for six months lacked documentation that antibiotic monitoring was completed, and the prior six months of records could not be located. The policy stated the IP would oversee antibiotic monitoring and work with the MD, pharmacist, nursing, and admin leadership, and the IP confirmed the program was not implemented.
A resident with hyperlipidemia, DM, and depression was found asleep in bed with a cup of seven pills on the bedside table. The resident had no physician order or care plan direction for self-administration of meds, and an RN confirmed he left the meds at bedside without determining whether it was safe for the resident to self-administer. The NHA and DON confirmed the same failure.
Inoperable bathroom call lights for two residents. The facility failed to ensure that bathroom call lights were accessible for two residents who were independent with toileting hygiene and toilet transfers. Both residents stated they would use the bathroom pull cord for help, but the cords were wrapped around grab bars and were inoperable. An LPN confirmed the issue, and the NHA and DON acknowledged the call lights were not accessible.
Failure to maintain oxygen equipment and provide appropriate respiratory care for two residents. One resident’s oxygen tubing was found past the weekly change interval, and another resident’s oxygen tubing was located in the bathroom, blocked by an electric wheelchair, and not stored in a treatment bag or labeled with a date. The residents had orders for oxygen therapy, and an LPN, RT, and the NHA confirmed the findings.
Failure to Provide Trauma-Informed Care: A resident with anxiety, depression, and later-documented PTSD history did not have PTSD included on the MDS or in the care plan. Social services notes stated the resident did not report trauma, but later progress notes documented a past traumatic experience and PTSD history, and the resident reported childhood sexual abuse and abusive relationships. The NHA and DON confirmed the facility failed to provide culturally competent, trauma-informed care.
Failure to post current nurse staffing information. The facility did not ensure that the posted staffing sheet in the lobby reflected the current date, resident census, or accurate staffing hours for licensed and unlicensed nursing staff at the beginning of the shift. The NHA and DON confirmed the required information was not posted accurately.
Unsecured medication carts and alcoholic beverage: Two medication carts were found unlocked in a staff room and accessible to residents, visitors, and staff. The carts contained multiple medical supplies and biologicals, including expired items, and an unlocked refrigerator in the same room contained an unopened bottle of beer and other items. The DON confirmed the carts, alcoholic beverage, and room were not properly secured.
Failure to Hold Required QAA Meetings: The facility failed to conduct QAA meetings at least quarterly with all required committee members for three of four quarterly meetings. The NHA was unable to locate QAPI sign-in sheets for the review period, and later confirmed the facility did not meet the required QAA meeting schedule.
Surveyors found that multiple residents did not receive the food items listed on their tray tickets or requested by them, despite a facility policy requiring identification and honoring of individual dining preferences. One resident did not receive a chef salad and dressings as ordered, another repeatedly received unwanted chocolate pudding and did not consistently receive a requested daily banana, and another received dry ground chicken without the ordered barbeque sauce or marinated cauliflower. A further resident did not receive a double entrée as specified, and another reported often receiving food different from what was requested, while a family member stated that undated, rotating menus made it impossible to know what meals to expect. The posted menus were labeled only by week number without dates or indication of the current week, and the NHA confirmed that resident-selected menu items were not provided for several residents.
A resident with chronic medical conditions, depression, and moderate cognitive impairment had a documented history and care plan for sexually inappropriate behavior, including repeated sexually explicit comments and physical groping of CNAs, with incidents serious enough to involve local police and psychiatric evaluation. Psychiatry and primary care notes described ongoing inappropriate sexual comments and behaviors toward female staff and documented behavioral disinhibition related to a neurocognitive disorder. Despite these repeated, documented events and an abuse prohibition policy requiring investigation of possible incidents, facility records showed no investigation into whether the resident had been sexually inappropriate with other residents, and the DON and NHA confirmed that no such investigation had been conducted.
A transportation driver delivered an individual from dialysis who shared the same first name as a newly admitted resident expected back from treatment. The receptionist directed the driver to the resident’s room based on this information. The individual had no ID band, but staff took his photo, uploaded it to the EMR, and an RN and an LPN relied on his verbal acknowledgment of the shared first name and the new photo profile to identify him. Without confirming two identifiers or recognizing that he was not the admitted resident with ESRD and Parkinson’s disease, the LPN administered scheduled medications including Flomax, Sinemet, Vitamin D, and a multivitamin that were ordered for the actual resident. Later calls from the transport company and another facility revealed that the individual was a different resident from another facility who had been transported to the wrong location, confirming that medications had been given to the wrong person.
The facility failed to ensure call lights were accessible and answered promptly, as required by its own policy, for six cognitively intact residents with significant medical and functional needs. Several residents who were dependent or required assistance for toileting hygiene and transfers reported that staff response to call lights, especially on evening and night shifts, often took 30 minutes or longer, with one resident stating a CNA discouraged frequent call light use and made her wait to use the bathroom. Other residents described frequent delays of 30–45 minutes or up to two hours when requesting help for toileting, medications, or feeling unwell, and one resident who had soiled himself reported that repeated unanswered calls led him to contact his family, who then came to the facility and reported he was not being changed. Facility leadership acknowledged that call lights were not consistently accessible or answered in a timely manner.
A resident with a history of depression, prior Seroquel overdose, psychiatric hospitalization, and documented glycol toxicity was able to obtain and keep a gallon of Peak 50/50 antifreeze in their room, likely via frequent third‑party delivery services. The resident was cognitively intact but had a care plan noting risk for self‑harm ideation related to PTSD, glycol toxicity, and hallucinations. Staff, including the RN unit manager, were unaware of the resident’s self‑harm history, and no effective monitoring or controls prevented the resident from storing a toxic chemical in a closed cupboard. After the resident developed altered mental status and was sent to the hospital, the hospital reported abnormal labs and concern for antifreeze ingestion, prompting a room search that revealed the antifreeze jug. Hospital records documented acute kidney injury and metabolic acidosis due to ethylene glycol ingestion, and the surveyors determined that the facility failed to keep the environment free of accident hazards and to provide adequate supervision, resulting in actual harm and Immediate Jeopardy.
A resident with a history of self-harm, PTSD, depression, prior Seroquel overdose, and suspected ethylene glycol ingestion was care planned as being at risk for self-harm and had orders for psych consults and psychotropic medications, yet behavior monitoring was frequently undocumented over multiple months and the record lacked behavioral health interventions addressing prior suicidal attempts/ideations. Progress notes documented serious prior events, including ICU-level care for suspected self-harm with ethylene glycol and recent psychiatric hospitalization, but the NHA and DON reported they were unaware of the resident’s self-harm history and confirmed there was no facility procedure to ensure residents with prior self-harm attempts were referred to mental health services. The resident later exhibited altered mental status, was sent to the hospital, and staff subsequently found a gallon of antifreeze in the resident’s room after the hospital reported possible antifreeze ingestion, leading surveyors to cite the facility for failure to provide appropriate mental health treatment and services and to identify and manage residents with similar needs, at the Immediate Jeopardy level.
The NHA and DON did not effectively manage the facility to protect a resident with a known history of self-harm from accessing harmful chemicals, despite job descriptions assigning them responsibility for ensuring high-quality clinical care and compliance with regulations. Their failure to implement and oversee adequate protections allowed the resident to obtain and ingest ethylene glycol (antifreeze), leading to hospitalization and creating an Immediate Jeopardy situation. Both leaders acknowledged in interviews that they did not effectively manage the facility to prevent self-harm, resulting in noncompliance with applicable state regulatory requirements.
Medications and biologicals were found unsecured in two medication rooms, with doors left unlocked and medications left on the counter. Staff with keys acknowledged the requirement to keep these rooms locked but failed to do so, as confirmed by the DON and administrator.
A resident with a history of knee replacement, sleep apnea, and morbid obesity, who was cognitively intact, experienced a loss of prescribed Oxycodone when the medication card and tracking sheet went missing from the medication cart. Only two RNs had access to the cart during the relevant period, and the missing items were not recovered, resulting in a delay in pain management for the resident. The facility was unable to determine how the medication was misappropriated.
A resident's prescribed Oxycodone went missing, and the facility failed to follow its policies for investigating misappropriation of property. Only two RNs had access to the medication cart, and key narcotic documentation was missing or incomplete. The facility did not conduct all necessary staff interviews or require drug screening, and medication rooms were found unlocked with medications unsecured. The internal investigation was incomplete, and the missing controlled substance was not recovered.
Facility staff failed to provide adequate supervision and maintain a safe environment when a courtyard exit door, not connected to the wander guard or alarm system, was found propped open. A resident was observed unattended in the courtyard, another was attempting to exit, and visitors were using the door, despite signage indicating it should remain closed. Facility leadership confirmed the lapse in supervision and security for mobile residents.
A significant medication error occurred when an LPN, after being interrupted during medication preparation, administered another patient's insulin (30 units of NovoLog) to a resident with diabetes, end stage renal disease, and hypertension. The error was identified shortly after administration, and the resident required emergency department care for monitoring and treatment.
Multiple residents reported long delays in call light response, late medication administration, and untimely assistance with daily activities due to insufficient nursing staff. Observations included residents being left in soiled conditions, missed showers, and strong urine odors in rooms. Documentation and council minutes confirmed ongoing issues with inadequate staffing, leading to unmet care needs.
A resident with neurogenic bladder and multiple sclerosis, who was cognitively intact, experienced verbal abuse and neglect from a nurse aide. The aide used profanities, refused to provide proper care, left the resident undressed, and ignored requests for assistance. The incident was reported by the resident and her son, and the facility's investigation substantiated the abuse and neglect.
A shortage of clean linens, wash cloths, and towels was observed on all nursing units, with linen carts containing insufficient supplies for the facility's census. Laundry staff reported being unable to keep up due to a broken washing machine and limited staffing, and the administrator confirmed the ongoing equipment issue.
The facility did not maintain one of its two washing machines in safe operating condition, resulting in ongoing shortages of clean linens, wash cloths, and towels as reported by two residents and observed by staff. Only one laundry staff member was available, and laundry was not completed after their shift, leading to insufficient supplies.
Surveyors observed that the facility did not maintain sanitary conditions in the kitchen, including improper dish machine temperatures, unclean cooler fans, and multiple instances of dietary staff failing to follow hand hygiene and glove protocols while handling food and equipment.
A resident with severe cognitive impairment and multiple diagnoses was left in bed with an untouched breakfast tray, as staff failed to assist with cutting food into bite-sized pieces as required by the care plan. The LPN and DON confirmed the meal was not consumed or prepared for the resident, resulting in a lack of a dignified dining experience.
The facility did not ensure that call lights were accessible and answered promptly for most residents. In multiple cases, call light cords in bathrooms were found wrapped around grab bars, making them unusable. Residents reported consistently waiting thirty minutes or more for staff to respond to call lights, and this issue was documented in resident council meetings over several months. An LPN and the DON confirmed these deficiencies.
Over a six-month period, the facility did not address or respond to repeated concerns from the resident council regarding staff response to call lights. Despite policy requirements for communication and documentation, there was no evidence of follow-up or administrative action, and most residents interviewed reported ongoing dissatisfaction with the lack of resolution.
Residents repeatedly reported that food was tasteless, mushy, and unattractive, with buns becoming soggy from contact with liquids and pureed foods served in unappealing mixtures. During meal service, some residents did not receive dinner rolls and were given bread instead, and meal delivery was delayed. The Corporate Dietary Manager confirmed the failure to provide palatable and attractive food.
Multiple resident bathrooms were found visibly soiled with debris and stains, and toilets had stains of unknown origin, despite established cleaning procedures. The DON confirmed that the facility did not maintain a clean and homelike environment on one unit.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided, increasing the risk of accidents for a resident.
The facility repeatedly failed to maintain state-required staffing minimums for nurse aides, LPNs, and per patient day hours, despite having QAPI plans and audits in place. Multiple surveys found the same deficiencies, and staff confirmed that corrective actions were not effectively implemented.
A resident with a right arm fracture and their family raised concerns during a care plan meeting about staff not answering call lights. The facility did not document, investigate, or resolve this grievance in a timely manner, as required by its policy, and the DON confirmed the lapse.
A resident with severe cognitive impairment was allowed to attend a medical appointment unaccompanied, despite facility policy requiring an escort for such residents. The resident was left unsupervised after the appointment, left the premises independently, and was later found at his home. Review of records showed that several other residents with severe cognitive impairment also had orders permitting them to leave unaccompanied, and care plans lacked appropriate elopement interventions. Staff confirmed that supervision protocols were not followed, resulting in an immediate jeopardy situation.
A facility failed to protect residents from misappropriation of property by not ensuring proper documentation and accountability for controlled medications. Multiple residents experienced discrepancies between narcotic logs and MARs, with missing or unaccounted-for doses of oxycodone and tramadol. Staff statements revealed confusion over medication orders and destruction procedures, and leadership confirmed the failure to safeguard residents' belongings as required.
The facility did not follow required policies and state law to report allegations of neglect for two residents. One resident experienced an injury during a Hoyer lift transfer and reported that staff did not notify a nurse or supervisor. Another resident suffered a skin tear during a transfer when agency staff used the wrong level of assistance. In both cases, the facility failed to submit required reports of possible neglect to the state field office.
The facility did not follow its policies and procedures to investigate possible abuse or neglect for three residents. One resident with multiple health conditions was injured during a Hoyer lift transfer, and staff did not report or investigate the incident properly. Another resident suffered a skin tear during a transfer performed by a single CNA instead of two, with no follow-up investigation. A third resident with dementia was found with unexplained bruises, but the facility's investigation failed to interview all relevant staff. The DON confirmed that investigations were incomplete.
A medication cart and its narcotic drawer on the first floor were found unlocked and unattended, contrary to facility policy requiring carts to be locked when out of a nurse's view. This was confirmed by the unit manager, NHA, and DON.
A resident with multiple fractures and a traumatic pneumothorax was discharged without the home health services specified in their care plan and physician orders. Although referrals to home health agencies were made, none accepted the resident, and there was no documentation confirming that services were scheduled. The resident's spouse reported not being contacted by any agency, and staff confirmed the discharge plan was not implemented as required.
The facility failed to assess the clinical appropriateness of medication self-administration for three residents, leading to a deficiency. A resident with high blood pressure and depression was observed with a medicine cup of pills without a physician's order or assessment. Another resident with diabetes and high blood pressure was similarly found with medications without proper assessment. A third resident had opened medication bottles on their table despite being hospitalized. The facility's staff confirmed the failure to assess and secure medications properly.
Failure to Support Resident Choice for Outdoor Access
Penalty
Summary
The facility failed to ensure that residents were treated in a manner that promotes quality of life and failed to facilitate resident self-determination through support of resident choice for 15 of 32 residents reviewed. The cited concern centered on residents’ repeated requests to be able to go outside at the facility, with resident council minutes showing that residents had asked for this and a group interview confirming that they wanted access to the outdoors. During the interview, residents stated they could only go outside when family visited and took them out, and that residents without family or with limited family visits were not able to go outside. Resident R3 was admitted with cerebral palsy, hypertension, and diabetes and had a BIMS score of 15. During interview, R3 stated the facility allowed smokers to go outside but not other residents, and asked for help getting time outside. R3’s care plan identified sitting and relaxing outside as an activity preference. Resident R4 was admitted with heart failure, hypertension, and diabetes and had a BIMS score of 15. R4 stated that the only time she got outside was when her son or daughter visited, and she wanted fresh air, sunlight, and to see the plants. R4’s care plan stated it was important to go outside when the weather was good and enjoy eating, drinking, sitting, and talking to visitors. Resident R5 was admitted with hypertension, diabetes, and end stage renal disease and had a BIMS score of 15. R5 stated she did not like staying in her room or bed, liked to be out and about, and felt it was not fair that smokers could go outside while non-smokers could not. R5 also stated that many residents had been asking for this for months and nothing had happened. R5’s care plan identified going outside when the weather is good as important, along with activities such as gardening, sitting, talking, walking, bird watching, and wildlife observing. The Nursing Home Administrator and DON confirmed the facility failed to ensure residents were treated in a manner that promotes quality of life and resident choice.
Incomplete and inaccurate MDS assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for 17 of 24 residents reviewed. The cited issue involved Section C, Cognitive Patterns, and Section D, Mood, on multiple MDS assessments, where the Brief Interview for Mental Status (BIMS) and Resident Mood Interview were not completed even though the residents were documented as at least sometimes understood in Section B, Hearing, Speech, and Vision, or otherwise not coded consistently with the interview requirements in the RAI User's Manual. For each of the affected residents, the MDS showed Section C, Question C0100 as rarely understood, and the BIMS assessment was not completed. The same pattern was identified in Section D, where the resident mood interview was not completed. The residents reviewed included R6, R16, R36, R51, R58, R59, R60, R67, R75, R93, R96, R105, R109, R129, R130, R134, and R139. Several of these residents were documented as usually understood, understood, or sometimes understood in Section B, yet the required interviews were still omitted. During interview, the LPN Assessment Coordinator confirmed that one resident's MDS was incorrect and stated that when a resident is at least sometimes understood, the BIMS and Resident Mood Assessments should be completed. Later, the Nursing Home Administrator and the DON confirmed that the facility failed to make certain that comprehensive MDS assessments were accurate and fully completed for the 17 residents identified in the review.
LPNs Lacked Acceptable CPR Certification
Penalty
Summary
Facility nursing personnel did not maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting, as required by facility policy and accepted national standards. Review of the facility policy showed that licensed nursing staff must have current CPR certification for healthcare providers with hands-on practice and in-person skills assessment, and that online-only certification is not acceptable. Review of the facility’s list of 42 licensed nurses and the CPR certification cards for LPN Employees E1, E3, and E4 showed that their certifications were for online-only CPR classes for non-healthcare providers and did not include a hands-on session. During interview, the NHA and DON confirmed that the facility failed to ensure current CPR certification for these three licensed nurses.
Failure to Provide Necessary ADL Care and Grooming Assistance
Penalty
Summary
The facility failed to make certain that necessary care and services were provided for six residents who were unable to complete activities of daily living independently. Facility policy required that residents receive the necessary care and services to maintain or improve ADL abilities, including assistance with grooming and oral hygiene when needed. The cited findings involved residents with varying cognitive and physical conditions, including dementia, Parkinson’s disease, schizophrenia, anxiety, COPD, muscle wasting, spinal stenosis, diabetes, chronic pain syndrome, coronary artery disease, and muscle weakness, with MDS assessments showing needs ranging from dependent to setup/cleanup assistance for personal hygiene. Resident R9 was observed with unkept fingernails and debris under and around the nails, and the resident stated the nails needed to be cleaned and trimmed; an LPN later confirmed the condition. Resident R16 was observed with unkept, very long, thick, and dirty fingernails, and the LPN confirmed the observation. Resident R13 was found still in a gown in bed with long fingernails, hair, and beard, and stated a desire for a haircut and to be clean-shaven. Resident R131 was observed with bed linen smeared with brown matter. Resident R81 stated that call light response on night shift was poor. The NHA and DON confirmed that the facility failed to make certain that necessary care and services were provided.
Missing CPR Certification Documentation for Licensed Nurses
Penalty
Summary
The facility failed to maintain documentation showing that its nursing personnel had current education and certification to provide basic life support, including CPR, for a resident requiring emergency care prior to the arrival of emergency medical personnel and subject to physician orders and the resident's advance directives. Review of the facility policy on CPR showed that licensed nursing staff were required to maintain current CPR certification for healthcare providers through training that included hands-on practice and an in-person skills assessment, and that online-only certification was not acceptable. The Nursing Home Administrator provided a list of 24 currently employed LPNs and 18 currently employed RNs, and copies of CPR certification cards were reviewed for licensed nurses. CPR certification cards were not available for 13 LPNs and 6 RNs, identified in the report as Employees E5 through E23. During an interview, the NHA and DON confirmed that the facility failed to maintain documentation that 19 of 42 licensed nurses had current education and certification to provide basic life support, including CPR.
Failure to Maintain Nutritional Status and Ordered Supplements
Penalty
Summary
The facility failed to implement interventions to maintain nutritional status for three residents reviewed for nutritional concerns. Facility policies stated that residents should maintain acceptable nutritional status and receive nutritional care and services consistent with their comprehensive assessments, including therapeutic diets that account for clinical condition and preferences. Resident R39 had diagnoses including chronic kidney disease, high blood pressure, and heart failure. The record showed an order to weigh the resident weekly for four weeks and then monthly, and the care plan directed staff to weigh as ordered and alert the dietician and physician to significant loss or gain. On 5/6/26, the resident was weighed twice three hours apart at 340 pounds and 353 pounds, with no additional weights to verify accuracy. The next documented weight was 6/10/26 at 354.4 pounds. Progress notes documented increased edema, significant weight gain, scrotal edema, visible edema to the penis and scrotum with increased pain, and transfer to the hospital for severe swelling and pain to the scrotum. The resident was admitted to the hospital with congestive heart failure and later returned after aggressive diuresis, with a readmission weight of 325.5 pounds. Resident R81 had diagnoses including spinal stenosis, diabetes, and a stage four pressure ulcer. A physician ordered 30 ml of liquid protein twice daily for wound healing, and the care plan included providing supplements as ordered. After the resident was transferred to the hospital for stomach pain, all medications were discontinued and reordered upon return, but the liquid protein was not reordered. The resident stated during interview that he had not been receiving the supplement. Resident R164 had diagnoses including hypertension, diabetes, and end stage renal disease. Orders for liquid nutritional supplement twice daily and fortified pudding twice daily were discontinued on 7/7/26, and the record showed a hospital stay during which speech therapy downgraded the resident to puree with honey thick liquids due to coughing while eating. After return to the facility, the record failed to include a diet order active from 7/7/26 through 7/16/26, and there was no reassessment by speech therapy upon readmission to confirm the resident could resume a regular texture, thin liquid diet. Further review also failed to include orders for the fortified pudding or liquid nutritional supplement.
Incomplete Dialysis Communication Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not consistently provided for two residents who required hemodialysis. Facility policy required a licensed nurse to complete the Hemodialysis Communication Record before the resident left for dialysis, send it with the resident, review the dialysis facility communication on return, evaluate the resident, and complete the post-hemodialysis treatment evaluation. Review of records showed one resident with diagnoses including hypertension, diabetes, and end stage renal disease had dialysis ordered three times weekly at an outside dialysis center, but the dialysis communication forms from 5/13/26 through 7/13/26 were incomplete on multiple occasions, including missing pre-dialysis, dialysis center, and post-dialysis documentation on several dates. The record also showed incomplete post-dialysis documentation on numerous treatment days. For the second resident, who also had diagnoses including hypertension, diabetes, and end stage renal disease and was ordered dialysis three times weekly at an outside dialysis center, the dialysis communication forms from 5/13/26 through 7/13/26 did not include dialysis communication sheets on several scheduled dialysis dates. Facility census information confirmed the resident was present on those dates, and progress notes did not show dialysis refusals or other documentation related to dialysis for those dates. During interview, the Nursing Home Administrator and DON confirmed the facility failed to maintain consistent dialysis communication for the two residents.
Missing Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented review of pharmacy recommendations or irregularities in a timely manner for four of five residents reviewed. The report states that a licensed pharmacist was to perform monthly medication regimen reviews, including review of the medical chart, to identify and report medication-related problems and other irregularities, and that recommendations were to be acted upon and documented by staff and/or the prescriber. However, the facility could not show that the physician reviewed and signed multiple consultant pharmacist recommendations for residents with ongoing diagnoses including Alzheimer’s disease, dementia, diabetes, depression, history of falling, high blood pressure, and insomnia. For Resident R6, the record showed several consultant pharmacist recommendations from 10/14/25, 11/5/25, 12/8/25, 2/28/26, 6/17/26, and 7/15/26, but the physician review and signature were not documented, and the facility could not provide documentation for recommendations dated 12/8/25 and 4/29/26. For Resident R7, recommendations dated 9/6/25, 11/5/26, 2/28/26, 3/31/26, and 5/27/26 lacked documentation showing physician review and signature. For Resident R11, recommendations dated 10/17/25, 12/8/25, 1/23/26, and 6/17/26 lacked physician review and signature. For Resident R101, recommendations dated 4/30/26, 5/30/26, and 6/17/26 lacked physician review and signature, and the facility could not provide documentation for recommendations dated 10/17/25 and 7/15/26. During interview, the DON confirmed the facility could not locate all past pharmacy recommendations and confirmed the missing physician signatures.
Failure to Track Infections Through Required Surveillance
Penalty
Summary
The facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for six of 12 months. Review of the facility policy, Infection Control Outcome and Process Surveillance and Reporting, indicated the Infection Preventionist was responsible for conducting regular outcome surveillance by collecting and documenting data on individual cases and comparing the data to written infection definitions, as well as process surveillance to review practices such as hand hygiene, glove use, and environmental observations. Review of the facility's infection control documentation for January 2026 through June 2026 failed to reveal surveillance for tracking infections for residents in four of those months, specifically January 2026, February 2026, March 2026, and April 2026. The previous six months, July 2025 through December 2025, were not available for review. During an interview on 7/16/26 at 11:00 a.m., the Infection Preventionist confirmed that the facility failed to accurately track communicable diseases and infections.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for six months, with infection control surveillance for January 2026 through June 2026 lacking documentation that antibiotic monitoring was completed. The facility policy on Antibiotic Stewardship, last reviewed 3/20/26, stated that the program would focus on monitoring antibiotic use, improving use by avoiding unnecessary or inappropriate antibiotics, and would be overseen by the Infection Preventionist in collaboration with the medical director, pharmacist, nursing, and administrative leadership. Review also found that the prior six months of surveillance records, July 2025 through December 2025, could not be located for review. During an interview on 7/16/26 at 11:00 a.m., the Infection Preventionist confirmed that the facility failed to implement an antibiotic stewardship program.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe for Resident R151 to self-administer medications. Facility policy stated that clients may self-administer medications only when specifically authorized by the prescriber, the center's IDT, and in accordance with self-administration procedures and state regulations. Resident R151 was admitted to the facility and had an MDS dated 4/24/26 showing diagnoses of hyperlipidemia, diabetes, and depression. During an observation on 7/13/26 at about 10:00 a.m., the resident was lying in bed asleep, and a cup containing seven pills was observed on the bedside table. The resident's physician orders did not include an order for self-administration of medications, and the care plan did not address self-administration. During interview, RN E21 confirmed he left the cup of medication on the resident's bedside table and confirmed the facility failed to determine whether it was safe for the resident to self-administer medications. The NHA and DON later confirmed the same failure.
Inoperable bathroom call lights for two residents
Penalty
Summary
The facility failed to make certain that call lights were accessible for two residents, R10 and R53, as required by facility policy. The policy stated that patients would have a call light or alternative communication device at each bedside, toilet, and bathing room so they could call for assistance when unattended, and that staff would respond promptly. Review of R10’s record showed admission on 6/3/24, diagnoses including non-Alzheimer’s dementia, diabetes, and seizure disorder, and MDS findings that she was independent with toileting hygiene and toilet transfers. During an interview and observation, R10 stated she would use the call light next to the toilet if she needed help in the bathroom, but the bathroom call light cord was wrapped around the grab bars and was inoperable. Review of R53’s record showed admission on 4/28/22, diagnoses including foot drop, non-Alzheimer’s dementia, and anxiety disorder, with MDS findings that she was independent with toileting hygiene and toilet transfers. During an interview and observation, R53 stated she would use the bathroom pull cord if she needed help, but the bathroom call light cord was wrapped around the grab bars and was inoperable. An LPN later confirmed that the call light cords for both residents were wrapped around the grab bars and could not be used, and the NHA and DON confirmed the facility failed to make certain that call lights were accessible.
Failure to Maintain Oxygen Equipment and Provide Respiratory Care
Penalty
Summary
Appropriate respiratory care was not provided for two residents, and oxygen equipment was not maintained as required. Facility policy reviewed on 3/20/26 stated that disposable oxygen set-up should be replaced every seven days and that oxygen delivery devices should be dated and stored in a treatment bag when not in use. Resident R3, who had diagnoses including cerebral palsy, hypertension, and diabetes, had physician orders for CPAP supplies to be changed or cleaned per manufacturer instructions and for oxygen at 2 liters per minute every evening and night shift. During observation and interview on 7/13/26, R3’s oxygen tubing connected to the oxygen concentrator was dated 6/30/26 and was confirmed by an LPN and RT to have been in place longer than the weekly change interval. Resident R8, who had diagnoses including CAD, multiple sclerosis, and diabetes, had a physician order for oxygen at 2 liters per minute as needed. During observation and interview on 7/13/26, R8’s oxygen tubing connected to the oxygen concentrator was found in the resident’s bathroom, blocked by an electric powered wheelchair, and the tubing was not in a treatment bag and was not labeled with a date. The Nursing Home Administrator later confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for Resident R99 in accordance with professional standards of practice, accounting for the resident's past experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. The facility assessment dated 7/13/26 indicated the facility would provide services for psychiatric/mood disorders, including PTSD, but the resident's MDS dated 5/11/26 listed diabetes, anxiety, and depression and did not include PTSD. The resident's care plan initiated 8/5/25 did not include a plan of care for PTSD. The social services assessment and documentation dated 8/9/25 stated the resident did not report a history of trauma or PTSD, and the assessment dated 2/19/26 stated the resident did not report a traumatic event such as physical or sexual assault, a natural disaster, or seeing someone be killed. However, a progress note dated 2/28/26 stated the resident had faced a traumatic event or experience in the past, and a progress note dated 3/19/26 stated the resident had a past psychiatric history of PTSD. The resident also stated during interview that she had been sexually molested as a child and had been in abusive relationships. Hospital discharge paperwork dated 8/5/26 indicated the resident had been seen by a doctor due to suicidal thoughts or actions. The NHA and DON confirmed the facility failed to provide culturally competent, trauma care for one of four residents.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift for two of six reviewed days. During an observation in the main lobby at the reception desk, the posted nurse staffing information showed the date of 7/10/26, and the resident census and staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care for the current date. During an interview, the NHA and DON confirmed that the facility failed to post the required current facility information for staffing hours and the facility census.
Unsecured medication carts and alcoholic beverage
Penalty
Summary
The facility failed to properly store and secure two medication carts, a treatment cart, and an alcoholic beverage. Facility policy stated that medications and biologicals are to be stored properly, accessible only to authorized personnel, and kept locked when not in use or attended. Another policy stated that alcoholic beverages supplied by a resident or resident representative are to be labeled and stored in a secure location after a physician order is obtained for consumption. During an observation, a resident was leaving the Staff Development room and two medication carts were found in that room unlocked and accessible by residents, visitors, and other staff members. The room also contained an unlocked refrigerator, two broken wheelchairs, two locked file cabinets, teaching materials for Nurse Aid training, a microwave, a coffee maker, and a broken electric reclining chair, and neither entrance door had a locking mechanism. The red medical cart contained multiple medical supplies and biologicals, including expired blood glucose test strips, expired normal saline, needles, oxygen tubing, suction tips, PPE, blood pressure cuffs, an oxygen face mask, an irrigation tray, tracheostomy supplies, an Ambu-bag, gauze, and a bag of normal saline. The beige medical cart contained a sterile drape and 11 single-blade disposable razor blades. The unlocked refrigerator contained a plate covered by a plastic bag with liquid pooling in the bottom, a can of Celsius, an expired multi-use vial of tuberculin skin test solution, two open soda bottles, an unopened bottle of beer, and a 66 oz bottle of coffee creamer with very little liquid remaining. The DON confirmed these observations and confirmed the facility failed to properly store and secure the two medical carts, the alcoholic beverage, and the non-resident room containing multiple hazards.
Failure to Hold Required QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three of four quarterly meetings, covering the period from August 2025 through March 2026. Review of the facility policy, Center Quality Assurance Performance Improvement Process, showed that QAPI activities were to be integrated across all care and service areas and include clinical care, quality of life, and resident choice. During an interview on 7/14/26 at 10:35 a.m., the NHA was unable to locate the sign-in sheets for the QAPI meetings from August 2025 through March 2026. During a later interview on 7/16/26 at 10:00 a.m., the NHA confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members as required.
Failure to Provide Resident-Selected Menu Items and Follow Posted Menus
Penalty
Summary
The facility failed to provide resident-selected menu items and to follow documented food preferences and diet tickets for multiple residents during a surveyed evening meal. Facility policy dated 3/15/26 stated that individual dining, food, and beverage preferences are to be identified for all residents and that tray tickets must reflect appropriate items based on diet orders, allergies, intolerances, and preferences. During an evening meal observation on 4/14/26, one resident’s tray ticket specified a chef salad with five Italian dressings, but the salad and dressings were not present on the tray delivered. Another resident’s tray ticket indicated chocolate pudding, and the resident reported having repeatedly told kitchen staff that she did not want chocolate pudding every day and that she requested a banana each morning but only received one two to three days per week. Additional residents did not receive the items listed on their meal tickets or requested by them. One resident’s tray ticket indicated ground molasses barbeque chicken and marinated cauliflower, but the resident received dry ground chicken without barbeque sauce and no cauliflower. Another resident’s tray ticket indicated a double entrée, but observation of the tray before any food was consumed confirmed that a double entrée was not provided. A further resident stated that the food often did not match what she requested, and her family member reported that they could not tell what meals to expect because the posted menu lacked dates and the meals did not follow the menu in a way that allowed them to determine the current week. The posted menu showed Week One, Week Two, and Week Three with no dates or signage indicating the current week. The Nursing Home Administrator confirmed that the facility failed to provide resident-selected menu items for five of nine residents reviewed.
Failure to Investigate Sexually Inappropriate Resident Behaviors Toward Peers
Penalty
Summary
The facility failed to investigate a resident’s known sexually inappropriate behaviors to ensure the safety of other residents. The resident, who had chronic kidney disease, diabetes, depression, and moderate cognitive impairment, was care planned for a tendency to exhibit sexually inappropriate behavior. Progress notes documented multiple incidents in which the resident made sexually explicit comments to CNAs, including asking a CNA "when are you going to let me hit that" and attempting to hit her buttocks with a shirt. A psychiatry note recorded reports from primary care that the resident had been groping staff private areas and making crude comments. Another progress note described an incident where the resident requested help scratching his back, then attempted to put his hand between a CNA’s legs and, when unsuccessful, grabbed her buttocks; the CNA was visibly upset and local police were notified due to this not being the first episode of sexual harassment toward a CNA. Subsequent psychiatry notes indicated ongoing concerning behaviors, including repeated requests for doors to be closed when female staff were present, and another incident of an inappropriate verbal remark to staff using the phrase "let me hit that." The psychiatrist documented that the resident’s presentation was consistent with a neurocognitive disorder with behavioral disinhibition and impaired judgment, possibly related to alcohol-related dementia or secondary gain, and that risk for recurrence remained. Despite these documented behaviors and the resident’s known history of sexual inappropriateness, review of facility-provided investigation documents did not show that the facility had taken steps to determine whether the resident had been sexually inappropriate with peer residents, in addition to staff. In interviews, the DON and Nursing Home Administrator confirmed that no such investigation had been completed, despite the facility’s Abuse Prohibition policy requiring identification and investigation of possible incidents or allegations.
Failure to Correctly Identify Individual Before Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to correctly identify an individual prior to medication administration, resulting in medications being given to a person who was not the resident for whom they were ordered. Facility policy required that all patients receive an identification bracelet upon admission, with any refusal documented in the medical record, and that nurses verify the right patient as part of safe medication administration. On the date of the incident, a resident with end stage renal disease and Parkinson’s disease had been admitted to the facility and was receiving outpatient dialysis three times weekly. That morning, this resident had been sent out for dialysis. Later that day, a transportation company driver arrived and told the receptionist he was returning the resident from dialysis. The receptionist, relying on the driver’s statement and the expectation that the newly admitted resident was returning, directed the driver to the resident’s room. The individual brought in by the driver was not wearing an ID band. Staff proceeded with the admission process, including taking a photograph and uploading it into the electronic medical record. A day-shift RN evaluated the individual, verified the photograph in the electronic record, and asked the individual to confirm his name; the individual verbally confirmed the first name that matched the expected resident. Based on this identification, the nurse administered scheduled medications including Flomax, Sinemet, Vitamin D, and a multivitamin, which were ordered for the actual resident with ESRD and Parkinson’s disease. Another nurse later documented that when she asked the individual to state his name, he mumbled and gestured, did not answer questions directly, but did not deny being the expected resident. The LPN who administered medications noted that the patient did not have a name band but had a picture in the profile, and that when asked his name he nodded and answered "yeah" before she gave the medications. Subsequent phone calls from the transportation company and another facility revealed that the individual was actually a resident of another facility with the same first name, who had been transported to the wrong location. Staff interviews and statements confirmed that the facility had not correctly identified the individual using required identifiers before administering medications, resulting in a significant medication error.
Failure to Ensure Timely and Accessible Call Light Response for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were accessible and answered promptly, as required by facility policy and state regulations, for six of seventeen residents. The facility’s call light policy dated 7/15/25 states that each patient will have a call light or alternative communication device at the bedside, toilet, and bathing room, and that staff will respond promptly. Despite this, multiple residents with intact cognition (BIMS scores ranging from 13 to 15) reported delays in staff response to call lights, particularly on evening and night shifts, and facility leadership confirmed that call lights were not answered in a timely manner. One resident with chronic respiratory failure, retropharyngeal and parapharyngeal abscess, and fibromyalgia, who required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers, reported in a written statement that a nursing assistant criticized her for using the call light too much and made her wait to go to the bathroom. Another resident with spastic quadriplegic cerebral palsy, diabetes mellitus, and anxiety disorder, who was dependent for toileting hygiene and unable to perform toilet transfers due to medical condition, stated during interview that when she used the call light it often took thirty minutes or more to receive help, and that she could not care for herself and simply had to wait. Additional residents also described frequent delays in call light response. A resident with multiple sclerosis, a stage IV pressure ulcer, and malnutrition, who was independent with toileting hygiene but required partial/moderate assistance with toilet transfers, reported that it took thirty to forty-five minutes to get help, especially on evening and night shifts, occurring a couple of times each week. Another resident with COPD, diabetes mellitus, and depression, independent in toileting hygiene and toilet transfers, stated that when using the call light for needs such as medication or feeling unwell, waiting times on evenings and nights were about thirty minutes or longer. A long-stay resident with hypertension, heart failure, and depression, dependent for toileting hygiene and unable to perform toilet transfers, filed grievances on two consecutive days about daily call light wait times on evening and night shifts, later reporting that although things had improved, she still waited thirty minutes to two hours several times a week. A further resident with hypertension, diabetes mellitus, and cellulitis, requiring substantial/maximal assistance for toileting hygiene and toilet transfers, reported in a written statement that he repeatedly tried to call because he had soiled himself and no one came, leading him to call his family, who then came to the facility and reported he was not being changed. The Nursing Home Director and DON confirmed that the facility failed to ensure call lights were accessible and answered timely.
Failure to Prevent Resident Access to Antifreeze Resulting in Ethylene Glycol Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from access to harmful chemicals, resulting in the ingestion of ethylene glycol (antifreeze) and subsequent hospitalization. Facility policy on accidents and incidents required reporting, review, and investigation of all accidents/incidents, including determining root causes and contributing factors and identifying measures to reduce further occurrences and adverse outcomes. Despite this policy, a resident with a known history of self-harm behavior and psychiatric issues was able to obtain and keep a gallon of Peak 50/50 Prediluted Antifreeze in their room without detection by staff. The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including toxic effects of glycols, Parkinson’s disease, and depression. Medical documentation showed prior attempts or suspected attempts at self-harm, including a recent hospitalization for Seroquel overdose and a voluntary psychiatric admission. Hospital records further documented that the resident had been hospitalized for acute kidney injury and metabolic acidosis due to ethylene glycol ingestion, with progress notes indicating suspected self-harm with ethylene glycol requiring ICU care, intubation, and temporary dialysis. The resident also had a history of cocaine use and overuse of Seroquel, and the care plan identified potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations. Following another episode of altered mental status, the resident was transferred to the emergency room, and the hospital later contacted the facility with concerns that the resident had ingested antifreeze and requested a search of the resident’s room. Staff then found a gallon jug of Peak 50/50 Prediluted Antifreeze in the resident’s closed cupboard inside a yellow dollar store bag, without a receipt. The LPN who located the jug reported that the cap still had a plastic seal around the lid, but he was able to twist the lid off without breaking the plastic seal. Staff interviews indicated that the resident frequently used third-party delivery services such as DoorDash, and that the resident was generally quiet, stayed to herself, did not use the call bell, and kept her door or privacy curtain closed. The RN Unit Manager stated he was not aware of the resident’s history of self-harm. These circumstances show that the resident was able to obtain and store a toxic chemical in her room, despite her documented psychiatric history and prior glycol toxicity, and without staff awareness or intervention, leading to ingestion of ethylene glycol and hospitalization. The survey identified this failure to ensure protection from accident hazards and to provide adequate supervision as having resulted in actual harm to one resident and constituting an Immediate Jeopardy situation. The deficiency was cited under multiple state regulatory provisions related to licensee responsibility, management, clinical records, resident care planning, and nursing services.
Removal Plan
- Complete an initial audit to identify any resident with a diagnosis of self-harm attempt or ideation and update care plans with interventions.
- DON or designee will educate staff on the accidents policy (OPS100).
- Establish a protocol related to DoorDash and other deliveries; share it at the AD HOC resident council, communicate to families via Regroup, and educate staff.
- DON or designee will complete an audit to verify residents with self-harm attempts and/or ideation are placed on psych services, have a care plan initiated, and have interventions added to the Kardex.
- Report audit results to the QAPI Committee.
Failure to Provide Appropriate Mental Health Services and Monitoring for Resident With Self-Harm History
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a history of self-harm and significant mental health diagnoses received appropriate treatment and services to address assessed psychosocial problems. The resident was re-admitted with diagnoses including toxic effects of glycols from suspected antifreeze ingestion, Parkinson’s disease, and depression. The resident’s care plan, updated on 10/30/25, identified a potential risk for ideations of self-harm related to PTSD, glycol toxicity, and hallucinations. Physician orders from 10/25/25 through 12/3/25 included psychiatry/psychology consultation and medications for insomnia, anxiety, depression, and overdose reversal, and progress notes documented a recent voluntary psychiatric hospitalization for Seroquel overdose and a history of possible self-harm attempts, which the resident denied. Despite these identified risks and orders, the clinical record showed inconsistent behavior monitoring and a lack of documented behavioral health interventions to address the resident’s prior suicidal attempts or ideations. Behavior charting for October 2025 showed that 3 of 6 shifts lacked documented behavior monitoring, November 2025 had 24 of 90 shifts without documentation, and December 2025 had 26 of 61 shifts without documentation. The surveyor’s review of the medical records further noted a consistent lack of behavioral health interventions directed at the resident’s history of self-harm and suicidal ideation, even though the resident had a documented history of ethylene glycol toxicity, cocaine use, and Seroquel overdose, as well as recent psychiatric hospitalization. The deficiency also includes the facility’s lack of an effective system to identify and manage residents with prior self-harm attempts. On 12/21/25, the resident was noted to have altered mental status and was transferred to the emergency room. On 12/22/25, the hospital notified the facility of a possible antifreeze ingestion and requested a search of the resident’s room, where staff found a gallon of Peak 50/50 Prediluted Antifreeze. During interviews, the NHA and DON stated they were unaware of the resident’s history of self-harm and acknowledged that the facility did not have a procedure to ensure residents with prior self-harm attempts were referred to mental health services. Surveyors determined that this failure resulted in actual harm to the resident, required hospitalization for antifreeze ingestion, and that there was no system in place to ensure other residents with similar needs were receiving appropriate mental health services, constituting an Immediate Jeopardy situation.
Removal Plan
- Complete an initial audit of current and new admissions to identify any resident with a diagnosis of suicide attempt or suicidal ideation and update care plans with interventions.
- Educate the admission director and clinical liaison to attempt to identify potential needs related to suicide attempts or suicide ideations prior to admission.
- DON or designee will educate staff regarding any new admission with a history of past self-harm attempts on plan of care needs.
- DON or designee will complete a weekly audit on new admissions to determine whether any resident with a history of suicide attempt or suicidal ideation is placed on psych services, has a care plan initiated, and has interventions added to the Kardex.
- Report audit results to the Quality Assurance Performance Improvement Committee.
Failure of NHA and DON to Prevent Resident Self-Harm with Toxic Chemical
Penalty
Summary
The deficiency involves the NHA and DON failing to protect a resident with a history of self-harm from accessing harmful chemicals, resulting in an attempted self-harm incident. The facility job descriptions for the NHA and DON state that they are responsible for administering, directing, and coordinating all activities to ensure the highest quality of care, and for providing leadership and oversight of clinical care, nursing practice, and continuous improvement of nursing services. Despite these defined responsibilities, the NHA and DON did not ensure that federal and state guidelines and regulations were followed to prevent resident self-harm. Surveyors determined that this failure allowed a resident with a known history of self-harm to obtain and possess ethylene glycol, a chemical found in antifreeze. The resident ingested the ethylene glycol and required hospital admission. The incident created an Immediate Jeopardy situation for one of two residents reviewed (Resident R1). During an interview, the NHA and DON acknowledged that they failed to effectively manage the facility to protect residents from self-harm, confirming the identified deficiency under the cited Pennsylvania regulatory codes.
Failure to Secure Medications in Medication Rooms
Penalty
Summary
The facility failed to properly secure medications and biologicals in two of three medication rooms, specifically the TCU and Harmony Unit Medication Rooms. During a review of facility policy and on-site observations, it was found that the doors to these medication rooms were left unlocked, with medications designated for return sitting on the counter. The facility policy requires that medication rooms, cabinets, and supplies remain locked when not in use or attended by authorized personnel. Staff interviews confirmed that licensed nursing staff had keys to the medication rooms and were aware that the doors should be locked, yet the rooms were found unsecured during the survey. Further interviews with the DON and Nursing Home Administrator confirmed the failure to secure medications and biologicals as required. The deficiency was identified through direct observation and staff acknowledgment, with no mention of specific residents being affected or any adverse outcomes at the time of the survey. The findings were cited under relevant state pharmacy and nursing services regulations.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property, specifically regarding the loss of prescribed narcotic medication. The resident, who had a history of left knee replacement, obstructive sleep apnea, and morbid obesity, was assessed as cognitively intact with a BIMS score of 13. The resident had physician orders for Oxycodone HCL and Tylenol Extra Strength for pain management. According to medication administration records, the resident received multiple doses of both medications during the review period. On the night in question, two RNs were responsible for the medication cart containing the resident's narcotic medication. The narcotic count was verified as correct during shift changes. However, during an early morning medication request, one RN was unable to locate the Oxycodone card or the associated narcotic tracking sheet in the medication cart. Further investigation revealed that the original tracking sheet had been removed and replaced with a new one, and the missing count signoff sheet was later found unsigned in the recycle bin. The missing Oxycodone and its documentation were not recovered, and the resident experienced a delay in receiving pain medication as a result. Staff interviews and documentation confirmed that only the two RNs had access to the medication cart during the relevant period. There was no evidence that the resident was interviewed regarding the missing medication, and the facility was unable to identify a perpetrator. The incident was reported to the local police department. The deficiency was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to protect the resident from misappropriation of property.
Failure to Investigate and Secure Controlled Substances
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation of misappropriation of resident property, specifically related to the disappearance of a controlled substance prescribed to a resident. The resident had physician orders for Oxycodone HCL and Tylenol Extra Strength for pain management. Documentation showed that the Oxycodone card and associated tracking sheet were missing from the narcotic drawer when the resident requested pain medication, resulting in a delay in administration. The shift change count sheets and narcotic records were also found to be incomplete or missing, and the original documentation was later discovered in a recycle bin, unsigned by one of the nurses involved. Staff interviews and facility documentation revealed that only two RNs had access to the medication cart during the relevant period. There was no evidence that all necessary staff interviews were conducted, including with the resident, nor was there evidence that staff drug screening was required, requested, or offered. The facility was unable to account for the missing Oxycodone or the corresponding drug count record, and the investigation did not identify a perpetrator. The facility did file a report with the local police department, but the internal investigation was incomplete as key documentation and interviews were lacking. Additionally, during a facility inspection, medication rooms were found unlocked with medications left unsecured on the counter, contrary to policy requirements for controlled substances. The Director of Nursing confirmed that original shift change count sheets were missing, and only copies were available for review. The failure to follow established procedures for handling, documenting, and investigating the loss of controlled substances resulted in a deficiency related to the misappropriation of resident property.
Failure to Supervise Residents and Secure Courtyard Exit
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for residents with unrestricted access to the outdoor courtyard area. During an observation with the DON, the Garden exit door was found propped open, despite signage instructing that the door should remain closed and indicating it was not an exit. This door, located out of view of the nursing units, was not connected to the wander guard or alarm system. During the observation, a resident was seen unattended in the courtyard, another resident was attempting to exit to the courtyard, and visitors were also observed using the door. The DON confirmed that the door should not have been propped open at that time. Interviews with the NHA, DON, and ADON confirmed that the courtyard had recently become the designated smoking area and that the unsecured door allowed any mobile resident to exit the building when propped open, as it only locks when properly closed. The facility leadership acknowledged that this situation resulted in a failure to provide adequate supervision and maintain a safe environment for mobile residents, as required by facility policy and state regulations.
Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong insulin to a resident with diagnoses of diabetes mellitus, end stage renal disease, and hypertension. The resident was prescribed Lantus (glargine) and Lispro insulin at specific doses and times, as documented in the physician's orders and Medication Administration Record. However, during medication preparation, the nurse was interrupted and inadvertently gave the resident another patient's insulin, specifically 30 units of NovoLog, which was not prescribed for this resident. Following the administration of the incorrect insulin, the nurse notified the supervisor, and the resident's blood sugar was monitored, revealing a blood glucose level of 354. The resident's family and provider were informed, and the resident was subsequently sent to the emergency department, where she received intravenous D10w. The Director of Nursing confirmed that the facility failed to ensure residents are free from significant medication errors, as required by facility policy and state regulations.
Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of eight out of eleven residents, as evidenced by multiple resident interviews, observations, and documentation reviews. Residents reported long wait times for call light responses, delayed medication administration, and untimely assistance with activities of daily living such as getting in and out of bed. One resident described having to wait from early morning until late morning for assistance and reported being told by staff that they were not the only one needing help. Another resident stated that they had to call their family to get staff attention during the night. Observations included residents being malodorous, with one resident noted to have large amounts of a brown substance under their fingernails, and rooms with overpowering urine odors. Documentation showed significant gaps in incontinence care, with one resident not receiving documented care for over ten hours. Additional evidence from Resident Council meeting minutes and grievance reviews indicated ongoing concerns about insufficient staff to assist with changing soiled sheets and providing scheduled showers. Several residents reported not receiving showers on their scheduled days, with no refusals documented. One grievance detailed a resident remaining in bed without bathing assistance late into the morning. The Nursing Home Administrator confirmed that the facility did not have enough nursing staff to provide necessary care to maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.
Failure to Protect Resident from Staff-Initiated Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from staff-initiated abuse and neglect, as evidenced by the substantiated case involving a resident with neurogenic bladder and multiple sclerosis, who was cognitively intact with a BIMS score of 15. The resident reported that a nurse aide verbally abused her, used profanities, and refused to provide appropriate care, including leaving her undressed and not assisting her into her chair as requested. The resident described being left cold and upset after the aide removed all her clothing at once, ignored her requests for assistance, and made derogatory remarks. The aide's own statement confirmed a confrontation occurred, and the aide left the resident after the exchange. Facility documentation and interviews further revealed that the resident's son reported the incident, stating that the aide was verbally abusive and left his mother naked in bed. The facility's investigation substantiated the abuse, confirming that the staff member's actions constituted both verbal abuse and neglect of care. The Nursing Home Administrator acknowledged that the facility failed to protect residents from staff-initiated abuse, as required by facility policy and regulatory standards.
Failure to Maintain Adequate Clean Linens and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment across all seven nursing units due to a persistent shortage of clean linens, wash cloths, and towels available throughout the day. Observations revealed that linen carts contained only a limited number of sheets, towels, and wash cloths, which was insufficient for the current census of 168 residents. Interviews with laundry staff indicated that only one laundry employee was available, and a second washing machine had been out of service for three to four months, resulting in an inability to keep up with the facility's linen needs. The Nursing Home Administrator confirmed that the washing machine had been down for an extended period, contributing to the ongoing shortage of clean linens.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to ensure that all essential equipment, specifically one of two washing machines, was maintained in safe operating condition. Facility documentation and grievances from two residents, as well as concerns related to another resident, indicated a lack of clean linens, wash cloths, and towels. Observation revealed that only one washing machine had been operational for three to four months, and the sole laundry staff member was unable to keep up with the demand for clean linens. The laundry was not completed after the staff member's shift, resulting in insufficient linens. The Nursing Home Administrator confirmed that the second washing machine had been out of service for an extended period.
Failure to Maintain Sanitary Conditions in Kitchen and Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as evidenced by multiple observations during survey visits. The dish machine's wash cycle was only reaching 142 degrees Fahrenheit, below the required 150-165 degrees, and the rinse cycle reached 160 degrees, below the required 180-194 degrees. Additionally, the walk-in cooler fans had a white fuzzy substance on them, and these fans were blowing air directly over food items. These issues were confirmed by the HCS corporate Dietary Manager during interviews. Further observations revealed that dietary staff were not following proper hand hygiene and glove use protocols. One dietary employee was seen touching the outside of a bag, pulling out buns, and then handling food items without changing gloves or washing hands. The same employee left the tray line to retrieve mashed potatoes and returned to serving without hand washing or changing gloves. Two dietary aides entered the kitchen without beard guards and had to walk through the kitchen to obtain them. Another dietary aide was observed washing dishes, handling soiled items, and then removing clean items from the dish machine without washing hands or changing gloves. These lapses in sanitary practices were also confirmed by the HCS corporate Dietary Manager.
Failure to Provide Dignified Dining Experience for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a dignified dining experience to a resident on the secure memory care unit during breakfast meal service. The resident, who has Alzheimer's disease, morbid obesity, and a psychotic disorder, was assessed with a BIMS score of 2, indicating severe cognitive impairment, and required assistance with cutting food into bite-sized pieces prior to meals. According to the resident's care plan, staff were to assist with this task. However, during observations, the resident was found lying in bed with the breakfast tray placed within reach, but no food had been consumed, tasted, or cut into pieces. The dietary slip was accurate, and there was no evidence that the meal had been prepared or assisted as required. Staff interviews confirmed that the breakfast tray was delivered at 7:35 am and remained untouched by 10:00 am. The LPN verified that the food had not been consumed or cut, and the DON acknowledged the failure to provide a dignified dining experience for the resident. Facility policy requires treating each resident with respect and dignity, and the failure to assist the resident with their meal as outlined in the care plan resulted in the deficiency.
Failure to Ensure Accessible and Timely Call Light Response
Penalty
Summary
The facility failed to ensure that call lights were accessible and answered in a timely manner for 19 of 21 residents, as required by facility policy. Observations revealed that in at least two cases, call light cords in resident bathrooms were wrapped around grab bars, making them inoperable. Interviews with residents confirmed that some rarely used the call light, but had it available at their bedside and in the bathroom, although the bathroom call light was not functional. Staff, including an LPN, confirmed the inoperability of these call lights for the affected residents. Additionally, a group interview with residents revealed that the majority consistently experienced wait times of thirty minutes or longer for call light responses, leading to frustration. Review of six months of resident council meeting minutes showed ongoing complaints about untimely call light responses, with issues reported every month during the review period. The DON confirmed the facility's failure to ensure call lights were both accessible and answered promptly for the majority of residents identified.
Failure to Respond to Resident Council Concerns on Call Light Response
Penalty
Summary
The facility failed to respond to concerns raised by the resident council regarding staff response to call lights over a six-month period. According to the facility's Resident Council policy, a designated staff member is responsible for communicating resident concerns to the administration and ensuring responses are documented and reviewed. However, review of resident council minutes for six consecutive months showed that concerns about call light response were repeatedly documented without any evidence of follow-up actions or communication from administration. During a group interview, the majority of residents expressed ongoing dissatisfaction, stating that their concerns were not addressed or resolved. The Nursing Home Administrator confirmed that the facility did not respond to these concerns in a timely manner during the specified period.
Failure to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive to residents. Over a four-month period, resident council meeting minutes documented repeated complaints from residents about the food being tasteless, mushy, and unattractive, with specific mention of buns becoming soggy due to being placed on plates with liquids. During a resident group meeting, residents reported that the dietary department had not addressed ongoing food issues, and that food was sometimes not what was requested. Two residents interviewed also stated their only complaint was the taste and appearance of the food. Observation of tray line service revealed that, towards the end of service, some residents did not receive dinner rolls and were instead given pieces of bread. Pureed foods were served in a single glob, with mac n' cheese, stewed tomatoes, and meat mixed together, making the food unappealing. Buns for burgers, sloppy joes, or hot dogs were soaked with stewed tomato juices because the tomatoes were not served in a separate bowl. Additionally, meal delivery was delayed by 25 minutes beyond the posted time. The Corporate Dietary Manager confirmed that the facility failed to serve food that was palatable and attractive.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on one of five units, as required by its own policies and state regulations. During observation rounds with the DON, multiple resident bathrooms (rooms 507, 601, 602, 606, and 609) were found to be visibly soiled with debris and stains on the floors, and toilets had stains of unknown origin both internally and externally. Housekeeping staff described a seven-step cleaning procedure that included daily bathroom cleaning, but the observed conditions indicated that these procedures were not effectively implemented. The DON confirmed the failure to maintain a homelike environment in the affected unit.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the potential for accidents to occur. The lack of appropriate supervision and the presence of hazards directly contributed to this deficiency.
Failure to Correct Staffing Deficiencies and Implement Effective QAPI
Penalty
Summary
The facility failed to correct previously cited deficiencies related to staffing and compliance with state regulations, as evidenced by repeated findings across multiple surveys. Documentation review showed that the facility's QAPI program was intended to establish and implement performance improvement projects and monitor corrective actions, but the same deficiencies were cited in several consecutive surveys. Specifically, the facility did not maintain state-required staffing minimums for nurse aides, LPNs, and per patient day hours, despite having plans of correction that included regular audits and QAPI committee reviews. During the survey process, it was confirmed through staff interview, including with the Nursing Home Administrator, that the facility did not effectively address or resolve the identified quality deficiencies. The repeated failure to meet staffing requirements and to implement effective corrective actions as outlined in their QAPI plans led to ongoing noncompliance with state regulations.
Failure to Promptly Address Resident Grievance Regarding Call Light Response
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a resident's grievance as required by its own policy and regulatory standards. A resident who was admitted with a right arm fracture and attended a care plan meeting with family expressed concerns about staff not answering call lights. Although the facility's grievance policy requires that concerns be documented, investigated, and resolved in a timely manner, there was no evidence that a grievance form was completed or that the concern was investigated and resolved. Review of the facility's complaint log for the relevant month did not show any record of the grievance, and the Director of Nursing confirmed that the process was not followed for this resident's concern.
Failure to Supervise Severely Cognitively Impaired Resident During Offsite Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, resulting in an immediate jeopardy situation for multiple residents. Specifically, a resident with a BIMS score of 6, indicating severe cognitive impairment, was allowed to leave the facility unaccompanied for a medical appointment, despite facility policy requiring an escort for residents with a BIMS score lower than 13. The resident was not identified as at risk for elopement in the care plan, and the physician's order permitted the resident to leave unaccompanied when arranged by the facility. During the appointment, the resident was left unsupervised in the lobby, was not picked up as planned, and subsequently left the premises independently by calling a ride service and returning to his home. Review of facility records revealed that several other residents with severe cognitive impairment also had orders allowing them to leave the facility unaccompanied, contrary to the established escort protocol. Staff interviews confirmed that residents with severe cognitive impairment should not be permitted to leave unaccompanied, and that new residents should not have such orders until evaluated by a provider. Despite these protocols, the facility failed to ensure that care plans and physician orders were consistent with the residents' cognitive status and supervision needs. The incident was further compounded by the lack of elopement-related goals and interventions in the affected resident's care plan, and the absence of appropriate supervision during the transfer process. The resident was reported missing after the appointment, prompting a police search and notification of emergency services. The resident was eventually located at his home, having left the appointment site without facility staff knowledge or supervision. This failure to provide adequate supervision and to follow established protocols resulted in an immediate jeopardy situation for all residents with similar cognitive impairments.
Removal Plan
- Complete AMA discharge at residence.
- Call emergency services for hospital transfer for PICC removal.
- Notify Adult Protective Services.
- Notify Ombudsman.
- Review escort protocol.
- Educate staff on sending residents to appointments with escorts.
- Update elopement book.
- Conduct wellness check on resident.
- Conduct elopement drills every shift.
- Validate appointment returns.
- Develop protocol for offices to call building or driver for return and not put residents in the lobby.
- Review upcoming appointments and determine if escorts are needed in morning meeting.
- Update care plans.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically controlled medications, for 18 of 22 residents reviewed. Facility policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. Multiple discrepancies were identified in the handling and documentation of controlled substances, including oxycodone and tramadol, for numerous residents. In one case, a cognitively intact resident with chronic kidney disease, diabetes, and post-joint surgery care needs was found to have 27 tablets of oxycodone 10 mg missing, with no accountable documentation or explanation for their destruction or loss. Statements from staff revealed confusion and lack of clarity regarding medication orders, destruction of medication cards, and missing narcotic records. Further review of medication administration records (MARs) and controlled drug logs for other residents revealed numerous instances where narcotic medications were signed out on paper controlled drug records without corresponding documentation in the MARs. These discrepancies occurred across a range of residents and medications, including oxycodone and tramadol, with missing or inconsistent documentation of administration times and dosages. In several cases, staff statements indicated that medications were destroyed or wasted without proper documentation or clear understanding of the orders, and in some instances, medication cards were found in shred boxes or were unaccounted for entirely. Interviews with facility leadership confirmed the failure to ensure residents were free from misappropriation of property, as required by state regulations. The lack of proper documentation, inconsistent narcotic counts, and inability to account for missing medications directly contributed to the deficiency. The findings were based on a comprehensive review of facility policy, clinical records, incident investigations, and staff interviews.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of neglect for two residents. For one resident with diagnoses including spinal stenosis, heart failure, and osteoarthritis, and who required a two-person assist with a Hoyer lift, there was an incident during a transfer where the resident's leg was injured. The resident reported that her leg was trapped and that she called for help, but the aides did not notify a nurse or supervisor. The Director of Nursing later interviewed the resident, who provided a slightly different account, but no report of possible neglect was submitted to the state field office as required by facility policy and state law. For another resident with chronic obstructive pulmonary disease, muscle weakness, and a history of falls, who also required a two-person assist for transfers, an incident occurred where the resident was being transferred by a nurse aide and was lowered to the floor, resulting in a skin tear. The nurse aide involved was agency staff and used an incorrect level of assistance. Despite this, the facility did not report the possible neglect to the state field office as required. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not follow its own policies and procedures to report allegations of abuse and neglect for these two residents. The failure to report these incidents was in violation of both state law and the facility's own abuse prohibition policy.
Failure to Investigate Possible Abuse and Neglect Incidents
Penalty
Summary
The facility failed to implement its policies and procedures to investigate possible abuse and/or neglect for three residents. For one resident with spinal stenosis, heart failure, and osteoarthritis, who required two-person Hoyer lift transfers, there was an incident where the resident's leg was injured during a transfer. The resident reported that staff did not follow her instructions, did not seek nursing assistance when requested, and did not report the incident to a nurse or supervisor. The Director of Nursing later documented conflicting accounts and determined no further investigation or reporting was necessary, and no additional information was provided when requested. Another resident with COPD, muscle weakness, and a history of falls, also requiring two-person transfers, experienced a skin tear during a transfer when an agency CNA attempted to transfer her alone. The incident report noted the incorrect level of assistance was used, but no further investigation was conducted to determine if staff were aware of proper transfer procedures. A third resident with dementia and a history of wandering was found with two large bruises of unknown origin on her arm. The facility's investigation included statements from only a few staff, some of whom were not assigned to the resident during the relevant period, and failed to interview all staff who had provided care in the 72 hours prior to the injury. The Director of Nursing confirmed that the investigation was incomplete and that the facility did not follow its own policies and procedures for investigating possible abuse or neglect.
Failure to Secure Medication Cart and Narcotic Drawer
Penalty
Summary
The facility failed to ensure that medications were properly secured in one of three medication carts, specifically the first-floor medication cart for rooms 100-117. According to the facility's policy, medication carts must be securely locked at all times when out of the nurse's view. During an observation, the medication cart was found unlocked and unattended, and the narcotic drawer within the cart was also not secured. The surveyor was able to open the cart and narcotic drawer, and this was confirmed by the First Floor Unit Manager. The Nursing Home Administrator and the Director of Nursing later acknowledged that the medications were not properly secured as required.
Failure to Provide Discharge Planning Focused on Resident's Needs
Penalty
Summary
The facility failed to provide adequate discharge planning for one resident, as required by regulation. The resident was admitted with multiple serious injuries, including fractures to the ribs, right tibia, cervical spine, and a traumatic pneumothorax. The clinical record indicated that the resident was to be discharged with home health services, including PT, OT, RN, and aide support, as per physician orders and social services assessments. However, the discharge plan documentation showed that the resident was discharged without these home health services. Facility records revealed that referrals were made to home health agencies, but these agencies were unable to accept the resident for services. There was no documentation in the progress notes confirming that home health services were scheduled or provided. Additionally, the resident's spouse contacted the facility to report that they had not been contacted by any home health agency. During staff interviews, it was confirmed that the facility did not implement the required discharge plan for the resident.
Failure to Assess Medication Self-Administration
Penalty
Summary
The facility failed to assess the clinical appropriateness of medication self-administration for three residents, leading to a deficiency. Resident R2, who was admitted with high blood pressure, congestive heart failure, and depression, was observed holding a medicine cup of pills without a physician's order or assessment for self-administration. The Licensed Practical Nurse confirmed that she should have observed Resident R2 taking her medications. Similarly, Resident R3, with diagnoses including diabetes and high blood pressure, was found with a medicine cup of pills without a physician's order or assessment for self-administration. The Registered Nurse confirmed that she did not observe Resident R3 swallow her medications. Resident R4, admitted with congestive heart failure, high blood pressure, and anxiety, had opened bottles of Fluticasone nasal suspension and Refresh artificial tears on her over-the-bed table, despite being sent to the hospital and not present in the facility. There was no physician's order or assessment for self-administration for Resident R4. The Nursing Home Administrator and the Director of Nursing confirmed that the medications should have been locked in the medication cart and acknowledged the facility's failure to assess the clinical appropriateness of medication self-administration for these residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,188 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Of South Hi | 1.7 mi | ★★★★★ | 12 | 0 |
| Mcmurray Hills Rehabilitation And Healthcare Cente | 3.5 mi | ★★★★★ | 3 | 0 |
| Peters Township Post Acute | 3.7 mi | ★★★★★ | 11 | 0 |
| John J Kane Regional Center-sc | 4.4 mi | ★★★★★ | 3 | 0 |
| Providence Point Healthcare Residence | 4.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.