Highland Hills Post Acute

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain and follow physician orders for wound care and failed to provide appropriate treatment and care for a resident with a left knee surgical wound. Resident R1 was admitted with diagnoses including infection and inflammatory reaction due to an internal left knee prosthesis, high blood pressure, and a left artificial knee joint. Hospital discharge orders directed wound care to the left knee with cleansing using Vashe, patting dry, applying Adaptic film, and use of a wound VAC at 125 mmHg with changes on Monday, Wednesday, and Friday or as needed. Facility documentation also noted the resident had a left knee surgical incision and initially stated wet-to-dry dressing until the wound vac arrived. The record showed the wound VAC was not present when the resident arrived, and nursing documentation on 6/12/26 stated the ordered wound VAC treatment was not completed because the wound vac was not present yet. A resident representative reported that the dressing placed on 6/11/26 remained unchanged on 6/12/26 and that staff said there had never been an order to change it. The clinical record did not include physician orders for additional wound dressing care from 6/10/26 through 6/14/26, and it also lacked documentation that the left knee dressing was changed on 6/11/26, 6/12/26, 6/13/26, or 6/14/26. The DON confirmed on interview that the facility failed to obtain a physician order for wound care and failed to provide appropriate treatment and care in accordance with professional standards of practice for Resident R1.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to provide appropriate pressure ulcer care was identified for one resident who was admitted with diagnoses including high blood pressure, hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and a need for assistance with personal care. The resident's MDS indicated substantial to maximal assistance was needed to roll from side to side and return to lying on the back. Facility policy required individualized repositioning for residents at risk for pressure injuries, with repositioning every 2-3 hours when an appropriate pressure redistribution support surface is used, and required documentation of all services provided in the medical record. Review of the resident's care plan showed the resident was at risk for skin breakdown related to activity intolerance, cognitive impairment, and impaired mobility, with interventions to assist with turning and repositioning as indicated and tolerated. The June 2026 turn-and-reposition record showed multiple missed, blank, or marked NA entries on several shifts, with no documentation explaining why repositioning was not applicable. During interview, the resident stated that repositioning was not consistent and that some staff offered to turn and reposition while others did not. The DON confirmed the facility failed to make certain the resident received necessary treatment and services consistent with professional standards of practice to prevent pressure ulcers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that necessary resident information was communicated to receiving health care providers during transfers for two residents. Facility policy on transfer and discharge, last reviewed on 11/1/25, required that residents or their representatives receive written notification of impending transfer or discharge and that specific information be conveyed to the receiving provider, including practitioner contact information, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information, including a copy of the discharge summary. The policy also required that the medical record contain the discharge summary information and identify the recipient of the summary. For one discharged resident (R1), admitted on an unspecified date with diagnoses including hypertension, anxiety, and chronic respiratory failure, the clinical record showed the resident was transferred to the hospital on 3/8/26 and did not return. There was no documented evidence that the facility communicated the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or all information necessary to meet the resident’s specific needs to the receiving provider. For another resident (R3), admitted on an unspecified date with diagnoses of hypertension, diabetes, and hyperlipidemia, nursing notes documented an episode of unresponsiveness during lunch with abnormal vital signs, subsequent partial recovery, and a decision by the nurse practitioner to send the resident to the hospital with the niece’s agreement. Review of this resident’s record likewise revealed no documented evidence that the required information, including care plan goals, advance directives, instructions for ongoing care, resident representative information, and all necessary information, was communicated to the receiving provider. In an interview, the ADON confirmed the facility failed to ensure necessary information was communicated for these two residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to obtain appropriate physician orders related to a hospital transfer and to the management of blood glucose levels. One resident (R3), with diagnoses including hypertension, diabetes, and hyperlipidemia, became unresponsive and flaccid during lunch while in a wheelchair. Vital signs at that time showed blood pressure of 88/50, heart rate 75, oxygen saturation 95%, and respirations 26, and the resident required maximum assistance of four staff to return to bed. After returning to bed, the resident became more aroused, with blood pressure 110/58, heart rate 71, respirations 21, and oxygen saturation 94%, and was able to answer questions appropriately. The nurse practitioner directed that the resident be sent to the hospital for evaluation, and the resident’s niece agreed to the transfer; however, review of the physician orders showed there was no physician order documented for the hospital transfer. The ADON confirmed that the facility failed to obtain a physician order for this transfer. A second deficiency was identified for another resident (R2), who had diagnoses including anemia, diabetes, and hypertension. Review of this resident’s physician orders showed an order for Humalog (insulin lispro) 100 units/mL to be administered subcutaneously before meals and at bedtime according to a sliding scale based on capillary blood glucose readings, with specific insulin doses corresponding to blood glucose ranges from 0 to 400 mg/dL. However, the order did not include parameters for when to contact the physician regarding hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) in relation to these capillary blood glucose checks. During interview, the ADON confirmed that the facility failed to obtain physician orders that included management parameters for hypoglycemia and hyperglycemia for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary nail care for four out of ten residents who were unable to perform this activity of daily living themselves. According to the facility's policy, nail care should include daily cleaning and regular trimming. Observations and interviews revealed that several residents had long fingernails, some with brown debris underneath, and expressed that their nails had not been cut or cleaned by staff. One resident's representative reported having to cut the resident's nails themselves due to lack of care from facility staff. These findings were confirmed during walking rounds with the Assistant Director of Nursing, who acknowledged the deficiency. The affected residents had significant medical conditions, including stroke with hemiplegia, high blood pressure, difficulty swallowing, malnutrition, muscle weakness, dementia, low back pain, Parkinson's disease, and hip fracture. Despite these conditions, which limited their ability to perform self-care, the facility did not ensure that nail care was provided as required by policy. The deficiency was identified through review of records, direct observation, and interviews with both residents and staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve their mobility, as required by physician orders and facility policy. Three residents with diagnoses including stroke, high blood pressure, and hemiplegia had specific orders for the use of splints, braces, and guards to prevent contractures, maintain joint alignment, and support functional use of extremities. Documentation reviews revealed multiple instances where these devices were not applied as ordered, with records showing days marked as 'No', 'Not Applicable', or left blank, indicating the devices were not used or there was no evidence of their application. For one resident, the ankle brace was not applied on 14 out of 29 days, the palm guard on 6 days, the elbow splint on 14 days, and the hand brace on 15 days. Another resident did not have a hand splint applied on 18 out of 29 days, and during an interview, the resident stated they did not know the location of the splint. A third resident's hand splint was not applied on 14 out of 29 days, with documentation similarly marked as 'Not Applicable' or left blank. Interviews with residents and staff confirmed the lack of consistent application of prescribed orthotic devices. The Assistant Director of Nursing acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve mobility for all three residents reviewed. These findings were based on facility policy review, clinical record review, observations, and interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the confidentiality of a resident's personal and medical records as required by its own policy. During an observation, a sign was posted above a resident's bed that included specific medical information, such as the use of a specialized cup for thin water, instructions on limiting liquid intake to reduce aspiration risk, and the need for the resident to sit up while drinking. The resident's clinical record did not contain documentation indicating that the resident or their representative had approved the posting of this private health information. This was confirmed by the Assistant Director of Nursing during an interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the care plan for one resident to accurately reflect the current physician's order and the resident's needs. The resident, who had a history of stroke, high blood pressure, and difficulty swallowing, was admitted with a physician's order specifying 'No straws.' Despite this, a concern was raised by the resident's representative that the resident was still being given thin water through a straw. Review of the resident's care plan showed that the intervention 'No straws' was not included, and this omission was confirmed by the Assistant Director of Nursing during an interview. The facility's policy requires that care plans be updated as residents' conditions or orders change, but this was not done in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to make certain that equipment was in safe operating condition for the Automated External Defibrillators on the first and second floors and the crash cart on the second floor. Review of the facility’s Heart Start FRx 86/304 AED Owner Manual showed the AED has automatic self-test features and requires replacement of used, damaged, or expired supplies and accessories. Observation of the second-floor AED box revealed an AED with AED Smart Pads II attached that had an expired expiration date. Observation of the second-floor crash cart revealed the crash cart checklist log had not been completed for multiple dates. The RN Manager confirmed the crash cart checklist log was not completed and that the AED Smart Pads II were expired. Observation of the first-floor AED box also revealed an AED with AED Smart Pads II attached that had an expired expiration date, and an RN confirmed the pads were expired. The DON later confirmed the facility failed to make certain that the AEDs and crash cart were in safe operating condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its established emergency water storage procedures to ensure water would be available to essential areas during a loss of normal water supply. The facility policy, Emergency Preparedness and Planning dated 11/1/25, stated the emergency water supply recommendation from the Red Cross and FEMA was one gallon per person per day. The Emergency Water Supply plan identified a total bed capacity of 200 residents and 105 staff, for 305 total people, and calculated that 915 gallons would be needed for three days. During a tour with the Maintenance Director, the Long-Term Care Supply Room contained 16 boxes of one-gallon water containers, totaling 96 gallons, and the estimated storage volume for that area was 100 gallons. The Arcadia storage area contained 36 one-gallon jugs on top shelves and five-gallon jugs on lower shelves, totaling 161 gallons, with an estimated storage volume of 200 gallons. The Maintenance Director confirmed the facility did not meet the adequate volume for either storage area as outlined in the plan and stated additional water was present in boiler room water heaters, toilet tanks, and storage tanks; however, those sources were not acceptable for drinking water. The Nursing Home Administrator later confirmed the facility did not have the required amount of drinkable emergency water on hand for residents and staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to determine whether it was safe for residents to self-administer medications was identified for four residents. The facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe. For Resident R31, who had diagnoses including anemia, heart failure, and COPD, a bottle of nasal spray was observed on the bedside stand, but the physician orders and care plan did not include self-administration of medications. RN E10 removed the nasal spray and confirmed there was no order or care plan for self-administration. For Resident R102, who had COPD, anemia, and depression, a medicine cup with red liquid was observed on the bedside table, and the resident stated it was cough medicine kept there so it could be taken when desired; the physician orders and care plan did not include self-administration of medications. For Resident R70, who had chronic kidney disease, adult failure to thrive, and anemia, a medicine cup with four pills was observed at the bedside, and RN E12 confirmed the pills were unattended; the record lacked a physician order, assessment, or plan of care for self-administration. For Resident R40, who had COPD, morbid obesity, and muscle wasting and atrophy, an inhaler and a medicine cup containing four Tums were observed at the bedside, and RN E12 confirmed the medications were stored in the room inappropriately; the record also lacked a physician order, assessment, or plan of care addressing self-administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to include a hypoglycemia protocol in the physician orders for Resident R19. Resident R19 had diagnoses that included diabetes, COPD, and repeated falls, and his care plan dated 7/16/25 indicated that he was at risk for hyperglycemia and hypoglycemia and to initiate appropriate protocols. His physician orders dated 7/15/25 included insulin lispro three times per day with meals using a sliding scale, but the orders and physician notations did not include instructions for what to do if his blood glucose was below 70. During interviews, agency LPNs stated that hypoglycemia treatment should involve giving the resident something with sugar or glucose gel, and one LPN stated that the sliding scale should be in the physician order and may be put in separately. The DON confirmed on 12/17/25 that the facility failed to include hypoglycemia protocols in the physician orders for Resident R19 as required. The facility also failed to obtain current physician orders for treatments or medications for three other residents. Resident R10, who had diagnoses including hypertension, COPD, and hyperlipidemia, was observed with a handheld nebulizer on the nightstand, but the physician orders reviewed on 12/19/25 did not include medication for the nebulizer. Resident R102, who had diagnoses including COPD, anemia, and depression, was observed with a medicine cup containing red liquid described by the resident as cough medicine kept from the prior night, but the physician orders did not include cough medicine. Resident R149, who had diabetes mellitus, morbid obesity, and hepatic encephalopathy, was observed asking for her offloading boot for her right heel, but the physician orders dated 12/5/25 did not include an active order for the boot. An RN confirmed there were no current orders for the nebulizer medication and cough medicine, and the ADON confirmed Resident R149 did not have an active order for the offloading boot.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Appropriate respiratory care was not provided for four residents when respiratory equipment was observed out of compliance with the facility’s Respiratory Equipment Change and Cleaning Guidelines. The policy required handheld nebulizers, nasal cannulas, CPAP, and BiPAP equipment to be labeled and dated, and to be stored in a plastic bag when not in use. In one room, a handheld nebulizer was observed on the nightstand without a date and not stored in a bag, and an RN confirmed this. In another room, a CPAP mask was at bedside and not stored in a bag, and the ADON confirmed it was not in a bag and was not included in the care plan. In a third room, a CPAP machine was observed sitting on top of a fall mat on the floor and was not dated or stored in a bag, which the RN confirmed. In a fourth room, oxygen was in use via nasal cannula, and the tubing was not labeled with a date/time, which the RN confirmed. The residents involved had diagnoses including COPD, obstructive sleep apnea, hypertension, diabetes, aphasia, hemiplegia, CVA, and anxiety. One resident’s physician order directed CPAP use every night shift, and the MAR showed CPAP administration from 12/7/25 through 12/10/25, while the current care plan did not include management and use of the CPAP machine as ordered. The DON confirmed the facility failed to provide appropriate respiratory care for the four residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent cross contamination during a dressing change for one resident with a left heel wound. The resident had diagnoses of hypertension, diabetes, and depression, and had physician orders for the left heel wound to be cleansed, treated with Santyl ointment and calcium alginate, and covered with a foam dressing. During observation of the dressing change, the RN removed the soiled dressing, cleansed the wound, and continued applying the ordered treatments. The LPN assisting with the procedure placed the resident’s heel down on a washcloth used as a barrier, removed gloves, completed hand hygiene, returned to the treatment cart for a foam dressing, then came back, completed hand hygiene again, donned new gloves, lifted the resident’s leg, and allowed the RN to place the foam dressing. The RN confirmed hand hygiene was not completed after removal of the soiled dressing and cleansing the wound, and the LPN confirmed that placing the heel down on the washcloth and lifting it back up for dressing placement increased the risk of cross contamination to the wound. The facility also failed to manage Enhanced Barrier Precautions properly for three residents with indwelling Foley catheters. One resident was observed being assisted in the bathroom by NAs, with the Foley catheter under the wheelchair, and no gowns were observed on staff; the NA stated they were not aware that an indwelling catheter required EBP and gown use during care. Two other residents with Foley catheters were observed in their rooms or hallway, and their rooms failed to have signs posted on the door or wall outside the room communicating the precautions and PPE required. An RN confirmed that one resident’s doorway lacked signage to communicate the need for EBP. The DON confirmed the facility failed to prevent cross contamination during the dressing change and failed to ensure EBP were managed properly for the three residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate the call bell needs of one resident, identified as Resident R149, who had diagnoses including hepatic encephalopathy, diabetes mellitus, and morbid obesity. On 12/16/25, an observation showed that the resident's call light was activated at 9:29 a.m. but was not responded to until 9:45 a.m., resulting in a 16-minute delay. Facility-provided call bell audit documents revealed additional delayed response times for the same resident's room, including a 21-minute response on 12/11/25 and a 20-minute response on 12/12/25. During an interview, a registered nurse confirmed that the facility did not meet the resident's call bell needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with dementia, diabetes, and hyperlipidemia was subjected to verbal and possible physical abuse by an LPN during a transfer using a sit-to-stand lift. The resident's care plan specified that, in the event of conflict, she should be placed in a calm and safe environment and allowed to vent. However, during the transfer, the LPN was observed by the Assistant Director of Nursing (ADON) and a CNA to be yelling at the resident, telling her to stop acting like a child, and appeared to push the resident into a chair while the sling was still around her waist. The incident was documented in the nurse's note and corroborated by witness statements. The LPN involved had received annual re-education on psychosocial needs and abuse prevention, as indicated in her personnel record. Despite this training, the LPN's actions did not align with facility policy, which states that residents have the right to be free from abuse, neglect, and exploitation. The incident was reported to facility leadership, and it was determined that the facility failed to maintain an environment free of abuse for the resident, as required by state regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) for one sampled resident, R134, when Medicare coverage had ended and the resident was no longer Medicare eligible. The facility’s Medicare Advanced Beneficiary Non-coverage notices policy, reviewed 11/1/2024, stated that residents are to be informed in advance and in writing when Medicare payment denial or a change in coverage is likely, and that written notices are to be provided as soon as the facility determines Medicare payment certainly or probably will not be made. Resident R134 was originally admitted and later readmitted to the facility. His MDS dated 10/7/25 listed diagnoses including COPD, aphasia, hyperlipidemia, and hypertension. Facility documents showed that he had exhausted 100 days of Medicare and was no longer Medicare eligible as of 10/28/25, and census documentation identified him as Medicaid Pending as of 10/29/25. Review of his resident record, nurse notes, and social services notes did not show evidence that an SNF-ABN was provided, and during an interview on 12/16/25, the RNAC confirmed that the facility failed to provide the SNF-ABN as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a clean, safe, comfortable, and homelike environment in one common area used by residents, the vending machine area on Grand Heritage. The facility policy on homelike environment, last reviewed on 11/1/25, stated that the environment should be safe, clean, and comfortable, with comfortable and safe temperatures between 71° and 81°. During a resident council group interview on 12/16/25, three of eight residents reported that the Grand Heritage room with the vending machines was cold. On 12/17/25, the Maintenance Supervisor stated that some of the heating units needed to be replaced and that the issue had been ongoing for a couple of months. Later that day, during a tour of facility rooms and common areas, the vending machine room on Grand Heritage was observed to have a temperature of 55°.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one resident. The resident had diagnoses including anemia, heart failure, and a seizure disorder, and was identified as being at risk for falls related to altered balance while standing and walking. During observation, the resident was sitting in a chair with a thin scab on the left side of the forehead above the eyebrow. The clinical record documented that while a nurse aide was cleaning the resident on the bed and briefly left to go to the restroom, the resident was found on the floor beside the bed with a small skin tear on the left eyebrow and light bleeding that had stopped. The resident was assessed, vital signs were taken, and the resident was assisted back to bed. The facility’s investigation of the incident was incomplete. Employee statements indicated one nurse aide left the room to get water and returned to find the resident on the floor, while another staff member heard that the resident had fallen and then went to get the nurse. However, the facility’s investigation did not include signed and dated witness statements from all staff members who had contact with the resident during the shift when the incident occurred. During interview, the DON confirmed that the facility failed to conduct a thorough investigation of the injury obtained during care to eliminate possible neglect.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For Resident R127, the RAI User’s Manual stated that Section O0110 is used to identify special treatments, procedures, and programs received or performed during the assessment period, including CPAP use. Although the resident had diagnoses including high blood pressure, diabetes, and obstructive sleep apnea, the MDS did not indicate CPAP use. The clinical record showed a physician order for CPAP at night, the medication administration record documented CPAP administration from 12/7/25 through 12/10/25, the CPAP machine was observed at bedside, and the resident stated using the CPAP every night. The RNAC confirmed the MDS did not indicate CPAP use as required, and the care plan did not include management and use of the CPAP machine as ordered. For Resident R161, the MDS coded the resident as understood in B0700 and as having clear comprehension in B0800, while the BIMS score was 2, indicating severe impairment. The resident had diagnoses including high blood pressure, diabetes, and dementia. During observation, the resident was sitting sideways in a low bed facing the window and attempting to get out of bed. Staff interviews described the resident as difficult to redirect and communicate with, speaking a different language, having dementia, and not understanding or following instructions well. The DON confirmed the resident was confused and could not make self-understood or understand others, and that the MDS coding did not reflect the resident’s current needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one resident who had diagnoses including end stage renal disease, diabetes, and a skin infection. The resident’s care plan directed staff to administer medications as ordered, and physician orders required Tacrolimus for anti-rejection therapy. Facility records showed repeated instances in which Tacrolimus was not available or not administered as ordered, including notes that pharmacy would not deliver the medication, that the medication was unavailable, and that staff contacted the nephrologist and pharmacy because the ordered dose could not be provided. The MAR documented multiple missed or unavailable Tacrolimus doses across September, October, and November, including entries stating the medication was not available, pharmacy was notified, and only a different strength was on hand. The resident stated he had gone without Tacrolimus on four occasions. Staff interviews confirmed the medication had been unavailable at times, that pharmacy and the DON were made aware, and that the issue was related to pharmacy/insurance problems. The contracted pharmacist stated insurance rejections were common for this medication and that the submission was rejected because it was not appropriate for the location, with the medication later sent out after the delay.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store medications and biologicals properly and securely in two medication carts and two medication rooms. In the first-floor medication room, surveyors observed one bottle of liquid drug buster under the sink, a blue bowl under the sink containing twenty-two packets of resident medication, and another blue bowl on top of the refrigerator containing nine packets of resident medication. An RN confirmed the medication packets were in the blue bowls and stated they needed to be destroyed. The refrigerator temperature log in that room also had no recorded temperatures on multiple dates, and the RN confirmed the logs were not completed as required. In the first-floor medication cart four, surveyors observed opened medications without dates, including Clearlax, an albuterol inhaler, nasal spray, liquid Tylenol, and Geri-Tussin. In the second-floor medication room refrigerator, an opened TB vial was found without a date, and an RN manager confirmed it was not dated as required. In the second-floor medication cart number two, a bottle of prednisolone acetate 1% suspension was opened and without a date, and an LPN confirmed it was not dated as required. The DON later confirmed the facility failed to store medications and biologicals properly and securely in the identified medication carts and medication rooms.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide food products based on resident preferences and allergies for two residents. Resident R149, who was admitted with diagnoses of diabetes mellitus, morbid obesity, and hepatic encephalopathy, had physician orders listing allergies to chicken, fish, mushroom, and turkey. During interview, R149 stated the kitchen only gave her hamburgers when chicken, fish, or turkey was on the menu, even though there was an always available menu, and that her family had to bring her food when chicken was served. Resident R174, admitted with diagnoses of left femur fracture, protein-calorie malnutrition, and dementia, had physician orders listing allergies to milk, nuts, peanuts, and wheat. Observation of the lunch meal showed fish sticks, peas and carrots, and lemon pudding, while R174’s tray contained hamburger on bread, tartar sauce, peas and carrots, and lemon pudding. The Registered Dietitian confirmed that R149’s tray cards did not default to another menu item when an allergen was on the menu and were not individualized to her allergies.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, who had a diagnosis of dementia, hypertension, and insomnia, and was assessed as having moderately impaired cognition, exhibited a history of wandering and aggressive behaviors. Despite these risk factors, the resident was transferred from a secured dementia unit to a non-secured long-term care unit without documented interdisciplinary team review or updated elopement evaluation prior to the move. The care plan indicated the resident was at risk for elopement, but interventions and assessments were not consistently updated or implemented as required by facility policy. On the day of the incident, the resident was able to exit the facility through an emergency door that was not properly secured. Staff interviews and resident accounts confirmed that the door was either left unlatched or the resident was able to open it, possibly by guessing the keypad code or due to the door not being pulled shut. The resident was found outside in the parking lot, having exited the building without staff knowledge. Staff were unaware of the resident's absence until alerted by another resident, and there was no immediate staff presence in the area to prevent the elopement. Following the incident, it was revealed that there was no incident report completed, no documentation of family or physician notification, and no reportable notification to the Department of Health. The facility's policies on elopement, accidents, and care planning were not followed, as evidenced by the lack of timely assessment, care plan updates, and supervision. The Director of Nursing confirmed that the facility failed to provide adequate supervision, resulting in the resident's elopement and the creation of an immediate jeopardy situation.

Removal Plan

• Staff retrieved Resident R1 from the rear parking lot after being alerted by Resident R2.
• Nursing staff will be re-educated on updating the elopement care plan form immediate interventions and elopement assessment.
• All residents will be reassessed by the unit manager/designee for an elopement risk.
• All staff will be educated on elopement risk and assessments, care plans and supervision of residents by the unit manager/designee.
• A care plan with measurable goals and interventions for residents will be implemented to identify residents at risk for eloping by the unit manager/designee.
• Review and revise policies if needed to identify residents who are at risk for eloping.
• Door will be monitored by staff stationed at the door until vendor arrives to verify functioning of the door and residents are unable to exit.
• Facility will review the incidents at an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting.
• New admissions, change in condition or any new behavior will be monitored by the DON/designee to ensure elopement assessments are completed and care plans updated as required.
• Maintenance/designee will audit the doors are secure.
• Findings of audits will be submitted through facility QAPI program.
• Vendor will check that everything is functioning on the door, the magnetic lock and the keypad to the door itself.
• The door alarm will be set to alarm instantly instead of a delay.
• Deliveries will be changed to the front door.
• Code will be changed to an eight-digit number instead of four digits.
• All staff will be educated on risk, assessments, care plan, and supervision and verified with signatures.
• In-person interviews will be conducted of all staff to confirm education and understanding.
• Residents identified as elopement risks will be identified, including new residents at risk for elopement within the dementia secured unit.
• Policy will be reviewed and revised by the Director of Nursing to identify residents who are at risk for eloping.
• Door monitor by staff will be in place.
• Ad Hoc QAPI will be held.
• Audit tool for new admissions, change in condition or any new behavior will be used to ensure elopement assessments are completed and care plans updated as required and reviewed at the QAPI meeting.
• Audit by maintenance will be completed on the doors being secure and reviewed at the QAPI meetings.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a full-time qualified social worker for the period between 7/27/25 and 9/2/25, as confirmed by payroll documentation and an interview with the Human Resources Director. Payroll records showed that the previous social worker's last day was 7/27/25, and the new social worker did not begin employment until 9/2/25. This gap in employment was acknowledged by the Human Resources Director, indicating that the facility did not have a full-time qualified social worker on staff during this timeframe, as required by regulations for facilities with more than 120 beds.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to three out of five reviewed staff members, specifically two nurse aides and one LPN. According to the facility's own assessment, staff training on QAPI is required during general orientation upon hire, annually, and as needed. However, a review of training records revealed that these three employees did not receive the required QAPI education. This deficiency was confirmed during a telephonic interview with a human resources employee, who acknowledged the lapse in training documentation for the affected staff members.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. Resident R1, who had diagnoses including dementia and moderately impaired cognition, was identified in the care plan as requiring behavior monitoring due to frustration and aggression. Despite interventions such as diversional conversation and redirection, Resident R1 was involved in multiple incidents of physical aggression. On one occasion, Resident R1 entered another resident's room, refused to leave, and physically struck the resident and a staff member who attempted to intervene. On a separate occasion, Resident R1 was observed holding Resident R3 by the arm and striking her in the back with a closed fist while in the dining room. Staff intervened and separated the residents, and no injury was observed on Resident R3. Resident R3, who also had dementia with severely impaired cognition, was the victim in these incidents. The facility's policy required protection of residents from abuse by anyone, including other residents, and emphasized monitoring and intervention for those with behavioral issues. Documentation and staff interviews confirmed that the facility did not ensure Resident R3 was free from abuse by Resident R1, as required by policy and regulation. The Director of Nursing acknowledged the failure to protect the resident from abuse.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of two separate allegations of abuse involving two residents. In the first incident, a resident with moderately impaired cognition and diagnoses including dementia and insomnia was found outside the facility in the parking lot near a fire hydrant after eloping through an emergency door that was not locked. Documentation of the event, including notification to the family and physician, was missing from the clinical record, and the facility did not investigate the elopement or report it as required by policy. Staff and resident interviews confirmed the resident's exit through the emergency door, which was used for supply deliveries and was not secured at the time. In the second incident, another resident with severely impaired cognition and multiple diagnoses, including dementia and muscle weakness, was physically struck in the back by the first resident while in the dining room. Staff witnessed the event and completed two witness statements, but the physical abuse was not reported as required, and the facility did not follow its written policies and procedures for investigating abuse. The Director of Nursing confirmed that the facility failed to ensure a complete and thorough investigation in both cases.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report and investigate two separate incidents involving suspected abuse and neglect for two residents. In the first incident, a resident with moderately impaired cognition, dementia, and insomnia was found outside in the parking lot near a fire hydrant after eloping from the facility through an emergency door that was not locked. The event was discovered by another resident, who alerted staff. There was no documentation of the event in the clinical record, and required notifications to the family and physician were not completed. The facility did not investigate the elopement or the possibility of neglect, nor did it report the incident as required by policy. In the second incident, a resident with severely impaired cognition, dementia, muscle weakness, and coronary artery disease was physically struck in the back by another resident while attempting to walk past with a walker. Staff witnessed the event and completed witness statements, but the physical abuse was not reported as required. The Director of Nursing confirmed that both the elopement and the resident-to-resident abuse incidents were not reported according to regulatory requirements.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a thorough investigation and proper reporting following an elopement incident involving a resident with dementia and moderately impaired cognition. The resident, who had diagnoses including high blood pressure, dementia, and insomnia, was found outside in the parking lot near a fire hydrant after exiting through an emergency door that was not locked. The event was discovered by another resident, who alerted staff after noticing the door was open and the resident was outside. Staff interviews confirmed that the door was used for deliveries and was not secured at the time, allowing the resident to leave the building unsupervised. Review of the clinical record revealed that there was no documentation of the elopement event, nor was there evidence of required notifications to the resident's family or physician. Additionally, the facility did not initiate or complete an investigation into the incident or the possibility of neglect, as required by facility policy. The Director of Nursing confirmed that no investigation was conducted, and the event was not reported to the appropriate agencies, constituting a failure to respond appropriately to an alleged violation.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of stroke, hemiplegia, and aphasia, who was admitted to the facility, did not receive appropriate services and equipment to maintain or improve mobility. The resident was observed in bed without a hand splint, although a hand splint was present in the bedside stand. The resident had previously been discharged from therapy to a Rehab Restorative transition program, which recommended the use of a right resting hand splint during the evening and removal in the morning. However, a review of the resident's current physician orders and care plan revealed no documentation or orders for the use of the right resting hand splint. Staff interviews confirmed that the recommendations from the Rehab Restorative Transition Program were not processed, and there was a failure in the facility's process for transitioning residents from rehab to the long-term care unit. This resulted in the resident not receiving the necessary equipment and assistance as outlined in facility policy and the resident's care needs.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient and timely medically-related social services to assist a resident with behavioral issues in transferring to a Veterans Affairs (VA) facility for a behavioral bed. The resident, who had diagnoses including high blood pressure, dementia, and insomnia, exhibited a pattern of aggressive and combative behaviors, including physical aggression toward other residents and staff, verbal abuse, and attempts to take items from other residents. Documentation shows that the resident was moved from a secured dementia unit to a non-secured LTC unit, after which the frequency and severity of behavioral incidents increased, resulting in multiple episodes of aggression and threats to staff and other residents. Despite the escalating behaviors and repeated incidents, there was a significant delay in the facility's social services department actively pursuing a transfer to the VA for specialized behavioral care. Initial efforts to contact the VA and initiate a transfer were documented, but after the departure of the original social worker, there was a nearly three-month gap before further transfer efforts resumed. During this period, the resident continued to display aggressive behaviors, including physical altercations and threats involving staff and other residents, and required multiple interventions from crisis services and law enforcement. The deficiency was identified based on the lack of timely and consistent social services intervention to facilitate the resident's transfer to a more appropriate behavioral care setting, as evidenced by the prolonged delay in follow-up and coordination with the VA. This failure to provide adequate social services support contributed to ongoing behavioral incidents and did not help the resident achieve the highest possible quality of life, as required by regulatory standards.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure that proper supervision was provided for residents identified as high risk for elopement. This failure resulted in a resident elopement, which created an immediate jeopardy situation. The NHA's job description required directing the day-to-day functions of the facility in accordance with federal, state, and local regulations to assure the highest degree of quality care. However, based on a review of the job description, facility and clinical records, and staff interviews, it was determined that the facility did not provide adequate supervision as required for high-risk residents. This deficiency led to a breach in the fundamental principles of treatment and care, and the facility did not ensure that residents received care in accordance with professional standards of practice and facility policies.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the State agency in writing of a change in the Nursing Home Administrator (NHA) at the time the change occurred. Documentation showed that the Interim NHA assumed responsibility effective 9/5/25, as indicated in the facility's password agreement document. During interviews, the Director of Nursing confirmed that the previous NHA was on leave and that the Interim NHA was acting as administrator. It was also confirmed that the required written notification to the State agency regarding this administrative change was not provided at the time of the change, which did not meet regulatory requirements.

Penalty

Inspection fine: $18,213

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required training on effective communication for two of five direct care staff members, specifically Nurse Aide Employee E15 and Nurse Aide Employee E5. Review of facility education documents and training records showed that these two staff members did not receive education on effective communication as mandated. This deficiency was confirmed during a telephonic interview with a Human Resource employee, who acknowledged the lack of training for the identified staff members. The findings reference violations of 28 Pa Code: 201.14 (a), 201.18 (b)(1), and 201.20 (a)(6)(d), which pertain to the responsibility of the licensee, management, and staff development requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident identified as a wander and elopement risk exited the facility unsupervised. The resident, who had a diagnosis of unspecified dementia and mood disturbance, was assessed as moderately cognitively impaired with a BIMS score of 9 and had a documented elopement risk score of 9. Despite being equipped with a wander alarm, the resident was able to leave the facility through a delivery door that was equipped with magnetic locks and an alarm system. The incident took place when the delivery door was left open and the alarm system was not engaged due to an employee accidentally entering a bypass code upon exiting. This allowed the resident to leave the building undetected. The resident was observed outside the facility by staff and was returned after being gone for approximately 14 minutes. At the time of the incident, the resident was appropriately dressed for the weather and was assessed for injury or emotional trauma upon return, with no concerns noted. Interviews and documentation confirmed that the last employee to use the door was a maintenance assistant, and only three staff members had access to the codes for the door, one of which allowed for bypassing the alarm system. The failure to ensure the alarm was properly engaged and to provide adequate supervision for a resident at risk for elopement resulted in the resident leaving the facility without staff knowledge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were protected from abuse, as evidenced by its handling of three separate allegations involving two residents. Both residents had significant care needs, including frequent incontinence and assistance with daily hygiene, grooming, and dressing. One resident reported to a Certified Occupational Therapy Assistant (COTA) that an employee, while assisting with incontinence care, touched her inappropriately and that she did not want him to assist her further. The other resident reported that the same employee opened her house dress without reason, looked at her, and ran his hand up and down her body, causing her fear. Additionally, the first resident reported that the employee pushed and shoved the second resident during a transfer to bed. All incidents were reported to a supervisor immediately by the COTA. Despite these reports, the facility did not recognize the allegations as sexual and physical abuse and failed to initiate or complete investigations into the incidents before allowing the accused employee to return to work. The employee was initially suspended but was brought back to work after receiving education, without the completion of the required investigations. It was only after several days that the facility realized not all allegations had been investigated, leading to the employee's suspension again. This failure to follow policy and ensure a thorough investigation before allowing the employee to have resident contact resulted in the facility not protecting residents from potential abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of three allegations of abuse involving two residents. Specifically, after two residents reported allegations of sexual and physical abuse by an employee to a Certified Occupational Therapy Assistant, the facility did not recognize or investigate the reported sexual abuse on the date it was reported. Documentation shows that the employee accused of abuse was suspended but returned to work the following day after receiving education, without a completed investigation into the allegations. Additionally, the facility did not assess one of the residents after the alleged abuse, nor did it notify the resident's physician or family as required. The clinical record lacked evidence of a physician assessment following the abuse allegation. These failures were confirmed by the Nursing Home Administrator, who acknowledged that the facility did not follow its own policies and procedures for investigating abuse allegations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report and investigate an allegation of sexual abuse involving a resident who required assistance with daily hygiene and incontinence care. The resident, who had diagnoses including high blood pressure, depression, and arthritis, and was frequently incontinent, reported to a Certified Occupational Therapy Assistant (COTA) that an employee assisting with incontinence care touched them inappropriately and that they did not want that employee to assist them further. The COTA immediately reported the incident to a supervisor. Despite the facility's policy requiring all allegations of abuse to be reported and investigated, the facility did not recognize, report, or investigate the allegation of sexual abuse. The Director of Nursing was made aware of the allegation on the same day it was reported, but no investigation was conducted, and the incident was not reported to the appropriate authorities. The Nursing Home Administrator confirmed that the facility was unable to provide documentation of an investigation or reporting for this incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a thorough investigation into three separate allegations of abuse involving two residents. According to the facility's own policy, all reports of abuse, neglect, exploitation, or misappropriation are to be reported to appropriate agencies and thoroughly investigated, with findings documented and reported. However, documentation revealed that when one resident reported to a Certified Occupational Therapy Assistant (COTA) that an employee had inappropriately touched them during incontinence care, the facility did not recognize or investigate this as an allegation of sexual abuse. Additionally, another resident reported to the same COTA that the same employee had opened their house dress without reason, looked at them, and ran his hand up and down their body, which was not thoroughly investigated. The roommate of this resident also reported that the employee pushed and shoved the resident during a transfer, but again, no thorough investigation was conducted. The review found that no witness statements or interviews of staff or residents were completed for these allegations. Furthermore, there was no documented assessment of one resident after the abuse allegation was made, and neither the physician nor the family was notified. The Nursing Home Administrator confirmed that the investigations were incomplete and did not meet the facility's policy requirements. These failures were cited under multiple Pennsylvania Codes related to management, resident rights, and nursing services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly respond to three abuse allegations involving two residents. In each case, the facility did not notify the physician or the residents' families after the allegations were made. Additionally, the facility did not complete a resident assessment following the abuse reports. The incidents included allegations of sexual and physical abuse during incontinence care and transfers, as reported by the residents to a Certified Occupational Therapy Assistant, who then informed a supervisor. Despite these reports, the facility did not recognize or investigate the allegations as required. The clinical records for both residents showed relevant diagnoses, including depression, heart failure, diabetes, and frequent incontinence, with care plans indicating the need for assistance with daily activities. Documentation revealed that no thorough investigation was conducted, as there were no witness statements or interviews with staff or residents. The Nursing Home Administrator confirmed that the abuse investigations were incomplete and that required notifications and assessments were not performed for the affected residents.

Penalty

Inspection fine: $9,496

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for residents with a Life Vest, a wearable defibrillator designed to protect residents from sudden cardiac death. This deficiency placed two residents in immediate jeopardy, impacting their health and safety. The report highlights that the facility did not provide adequate training or education to the nursing staff regarding the operation and care of the Life Vest, as evidenced by multiple staff interviews where employees expressed unfamiliarity with the device and its alarms. Resident R1 was admitted to the facility with a Life Vest, as indicated in the discharge form from the hospital. However, upon review of the clinical records and care plans, there were no specific instructions or physician orders related to the care and monitoring of the Life Vest. Interviews with various nursing staff members revealed a lack of training and understanding of the Life Vest's operation, including battery changes, alarm meanings, and bathing protocols. This lack of knowledge was consistent across several staff members, including registered nurses and nursing assistants, who were responsible for the care of Resident R1. Similarly, Resident R2 was also admitted with a Life Vest, but the facility again failed to provide the necessary training and education to the staff. The clinical records for Resident R2 also lacked specific physician orders and care plans related to the Life Vest. Interviews with nursing assistants caring for Resident R2 further confirmed the absence of training and understanding of the device. The facility's failure to ensure that nursing staff had the appropriate competencies and skill sets necessary to care for residents with a Life Vest resulted in immediate jeopardy for both residents.

Removal Plan

• Educate all clinical staff on the care and operation of Life Vests, including alarms, electrical shock dangers, battery care, garment laundering, monitoring and placement, skin integrity checks, and special needs for bathing.
• Clinical staff will complete competencies, pre and posttests.
• Obtain physician orders and ensure implementation for Resident R1, and R2.
• Develop a resident-centered comprehensive care plan outlining the care of Resident R1 related to the Life Vest.
• Update Resident R2's comprehensive care plan outlining the care related to the Life Vest.
• Obtain additional physician orders for the implementation of the Life Vest and ensure the orders are complete.
• Educate clinical staff on updates and policies related to specialty equipment.
• Educate Admission Staff on updates and policies related to specialty equipment.
• Update Resident R1's physician's orders and care plan.
• Update Resident R2's physician's orders and care plan.
• Review/develop and update the policy related to specialty equipment.
• Review/develop policy and procedure related to the admission of residents with anticipated equipment.
• Audit 100 percent of residents for Life Vests placement, operation, battery backup, and associated documentation daily for one week, weekly thereafter for three weeks, and monthly thereafter with reporting through QAPI.
• Conduct random competency audits of two clinical staff per shift that have assignment with Life Vest residents daily for one week, weekly thereafter for three weeks, and monthly thereafter with reporting through QAPI.
• Review the education plan by QAPI and further recommendations.

Penalty

Inspection fine: $9,496

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a baseline care plan that included necessary interventions for two residents who were admitted with specific medical needs. The baseline care plan, which should have been developed within 48 hours of admission according to the facility's policy, did not include the presence of a Life Vest for either resident. The Life Vest is a wearable defibrillator designed to protect residents from sudden cardiac death, and its omission from the care plan indicates a lack of comprehensive planning for the residents' care. Resident R1 was admitted with diagnoses of diabetes, coronary artery disease, and high blood pressure, yet their baseline care plan did not reflect the need for a Life Vest. Similarly, Resident R2, who was admitted with high blood pressure, heart failure, and diabetes, also had a baseline care plan that failed to include the Life Vest. The Director of Nursing confirmed the oversight during an interview, acknowledging the facility's failure to provide effective and person-centered care planning for these residents.

Penalty

Inspection fine: $9,496

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as Resident R1, which included necessary instructions for the use of a Life Vest. Resident R1 was admitted with diagnoses of diabetes, coronary artery disease, and high blood pressure. Despite physician orders on March 5, 2025, to change the battery for a Life Vest daily, the care plan dated February 8, 2025, did not include goals and interventions related to the Life Vest. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the incomplete care plan for Resident R1's needs.

Penalty

Inspection fine: $9,496

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a physician completed the initial comprehensive visit for three residents, identified as R3, R4, and R5. The clinical records for these residents indicated that their initial comprehensive assessments were conducted by Certified Registered Nurse Practitioners (CRNPs) rather than a physician, as required. Resident R3 was admitted with diagnoses including high blood pressure, depression, and muscle weakness, and their assessment was completed by CRNP Employee E12. Resident R4, diagnosed with Alzheimer's Disease, muscle weakness, and restlessness, had their assessment completed by CRNP Employee E13. Resident R5, with diagnoses of depression, urine retention, and arthritis, also had their assessment completed by CRNP Employee E12. During an interview, the Director of Nursing confirmed the facility's failure to comply with the requirement for a physician to conduct the initial comprehensive visit. This deficiency was identified through a review of clinical records and staff interviews, highlighting a lapse in adherence to regulatory standards. The report cites specific Pennsylvania Code regulations that were not met, emphasizing the responsibility of the licensee and the provision of nursing services.

Penalty

Inspection fine: $9,496

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that nursing staff possessed the necessary competencies and skills to care for residents equipped with a Life Vest, a wearable defibrillator designed to prevent sudden cardiac death. This deficiency was identified through a review of job descriptions, clinical records, and staff interviews. The job descriptions for both the NHA and DON, dated 11/1/24, outlined their responsibilities to manage the facility and oversee resident care in compliance with relevant standards and regulations. However, the facility's failure to provide adequate training and ensure staff competency in handling Life Vests resulted in an immediate jeopardy situation for two residents, identified as R1 and R2. During an interview, both the NHA and DON acknowledged their failure to manage the facility effectively in this regard.

Penalty

Inspection fine: $9,496

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care, both during regular operations and emergencies. This deficiency was identified through a review of clinical records, staff interviews, and the facility's assessment documentation. Specifically, the facility's assessment did not include the use of Life Vests, which are critical for residents with complex medical conditions such as coronary artery disease and heart failure. This oversight was evident in the cases of two residents who were admitted with Life Vests, yet the facility's assessment did not account for the specialized care and management these devices require. Resident R1 was admitted with a Life Vest following a hospital discharge, as indicated in the correspondence between the facility and the hospital. The resident's Minimum Data Set (MDS) documented diagnoses of diabetes, coronary artery disease, and high blood pressure. Similarly, Resident R2 was admitted with a Life Vest, with physician orders confirming its use. The facility's failure to include Life Vests in their assessment highlights a gap in identifying and planning for the specific needs of their resident population. The Nursing Home Administrator acknowledged this deficiency, confirming that the facility's assessment did not adequately identify the resources necessary for the care of residents with Life Vests.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately account for controlled substances for four residents, leading to a deficiency in pharmaceutical services. Resident R1, who was admitted with emphysema and lung cancer, had discrepancies in the administration of oxycodone ER and oxycodone 5 mg. The facility was unable to provide the narcotic sign-out sheets for these medications, and there were inconsistencies in the Medication Administration Record (MAR) and pharmacy shipping manifests. Resident R2, diagnosed with dementia, a history of stroke, and osteoarthritis, had issues with tramadol administration. The Controlled Drug Record showed additional doses signed out without corresponding documentation of administration. There were also instances where doses were signed out on multiple records for the same administration time, indicating a lack of proper tracking and documentation. Resident R3, with COPD and hemiplegia, and Resident R4, who had a knee replacement, also experienced similar issues with controlled substances. For Resident R3, additional doses of Norco were signed out without documentation of administration. Resident R4's records showed discrepancies in the number of oxycodone tablets signed out versus what was documented in the MAR. The facility's Director of Nursing and Nursing Home Administrator confirmed these deficiencies during interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to proper food storage and sanitation practices in the main kitchen, as observed during a survey. In the walk-in cooler, ground beef was found thawing on the second shelf, and deli turkey and bag salad mix were stored without dates. In the dry storage area, a metal bowl of raisin bran was uncovered and unlabeled, and various items such as liquid butter, oatmeal cream pies, and [NAME] buddies were stored without dates. The reach-in cooler contained American cheese, boiled eggs, and hot dogs, all lacking labels or dates. Additionally, the dish room was found to have unsanitary conditions, including a wall fan and walls with brown debris and an ice machine with a brown, slimy substance. These observations were confirmed by the Dietary Manager, indicating a failure to maintain sanitary conditions and proper food storage, which could lead to foodborne illness and cross-contamination.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a clean, safe, comfortable, and homelike environment for several residents, as evidenced by the condition of seven resident wheelchairs, which were observed to be corroded with dried food substances and grime. Additionally, structural issues were noted, including a continuous gouge in the wall of the Arcadia Dining Room and Resident R144's room. The facility also failed to maintain an adequate supply of washcloths for staff use on two of four units, as observed when a nurse aide was unable to find a washcloth for a resident's shower. The laundry room was found to be lacking clean washcloths, with the emergency linen storage area missing washcloths, and the District Manager of Housekeeping confirmed that washcloths were on back order. Furthermore, the facility did not ensure that privacy curtains were clean and sanitary in two resident rooms, as evidenced by visible brown stains on the room dividing curtains facing Residents R81 and R124. These deficiencies were confirmed through staff interviews, including with a Registered Nurse Supervisor and the Nursing Home Administrator, who acknowledged the facility's failure to provide a clean, safe, comfortable, and homelike environment. The report cites violations of specific Pennsylvania Code regulations related to the responsibility of the licensee and management.