Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Immaculatemarycenter For Rehabilitation&healthcare during CMS and state inspections, most recent first.
A resident who was legally blind and needed staff help with ADLs was involved in an incident during care when an NA lowered the bed without first explaining the action. The resident reported being hit in the face, while the NA stated the resident used profanity and the NA responded before leaving the room. The ADON and UM heard the resident yelling and investigated the situation.
Failure to Reduce Psychotropic Medication: A resident with severe cognitive impairment, dementia, depression, and bipolar disorder remained on Sertraline despite a consultant pharmacist’s recommendation for GDR and a later psych eval recommending discontinuation. The resident’s care plan identified risk for behavior symptoms related to dementia and bipolar disorder, and the medication order was still active with no physician follow-up.
Failure to develop comprehensive care plans for diabetes and a Foley catheter. Two residents had documented diagnoses and orders related to DM and indwelling catheter care, but the care plans were not initiated in a timely manner or were not developed at all. One resident had a Foley catheter with orders for every-shift care, securement, and drainage bag changes, yet the related care plans were delayed. Another resident with DM and diabetic retinopathy had monthly eye specialist instructions, but no care plan was developed for the DM diagnosis.
Failure to address abnormal lab results: A resident with multiple chronic conditions, including Down syndrome and intellectual disability, had low ACTH and high cortisol results. A physician note referenced possible adrenal disorders and stated the resident would be monitored, but the record did not explain what was being monitored and contained no documented nursing interventions after the abnormal labs.
Nephrostomy Bags Not Draining by Gravity: A resident with bilateral nephrostomy tubes and CKD was observed with both nephrostomy bags lying flat on the bed instead of draining by gravity. The resident stated staff always placed the bags on the bed, and the ADON confirmed the observation. Facility policy called for the nephrostomy tube to be placed below the level of the kidneys.
Failure to maintain nutrition parameters for two residents. One resident with dementia, dysphagia, and muscle wasting had significant weight loss and swallowing difficulty documented, but the weight loss was not addressed promptly and the nutrition assessment did not specify the type or frequency of supplements. Another resident with dysphagia, muscle wasting, and multiple comorbidities had no admission weight, no documented dietary intervention for major weight discrepancies, and no re-weigh after a large weight change; staff later confirmed there was no documented evidence of dietary intervention for the weight loss episodes.
Medication Storage Room Temperature Out of Range: Drugs and biologicals in one medication storage room were not stored in accordance with accepted standards. The room on 4 South was observed at 80 F, above the recommended 68 F to 77 F range, and 15 medications plus multiple OTC products were stored there at temperatures exceeding labeling guidance. The unit manager confirmed the elevated temperature and that there were no prior documented room temperature logs.
A resident with severe cognitive impairment and dementia had seizure-like activity, prompting a physician to order labs. The labs resulted with multiple out-of-range values, but the record showed no documented physician review or follow-up, and an LPN confirmed there was no evidence the results were discussed with the physician.
A resident with severe cognitive impairment, dementia, malnutrition, and dysphagia was ordered a puree diet after SLP documentation showed pocketing and inability to clear food. During a lunch observation, the resident was served pureed food but was eating regular cake with hands, and an LPN stated the cake was allowed despite the puree diet order; the SLP confirmed there were no diet exceptions.
A resident with dementia and impaired mobility exited a secure unit after staff failed to identify them as at risk for elopement due to an inaccurately coded assessment. The resident followed dietary staff into an elevator and was mistaken for a visitor by front desk staff, allowing them to leave the facility unnoticed. The absence of a visitor sign-out process contributed to the oversight, and the resident was found two hours later at a family member's home after traversing busy streets.
A resident with dementia and physical impairments exited a locked unit and left the facility unsupervised after staff failed to recognize them as a resident. The individual was able to leave with the assistance of dietary staff and was mistaken for a visitor by the receptionist, leading to their exit. The resident was found two hours later, over a mile away, after traversing busy areas. The lack of effective supervision and inadequate processes for monitoring contributed to this Immediate Jeopardy event.
A resident with dementia, muscle weakness, and major depressive disorder was incorrectly assessed as not at risk for elopement, despite documentation of cognitive impairment. An LPN confirmed that the assessment did not accurately reflect the resident's condition or decision-making ability.
A resident with diabetes and multiple wounds did not receive recommended wound care or blood glucose management as advised by podiatry. Despite repeated high blood glucose readings, staff did not notify the physician or adjust care, leading to worsening wounds and hospitalization for infection.
A resident with moderate hearing difficulty was not provided with necessary hearing services after her hearing aid went missing shortly after admission. Despite care plan interventions for hearing loss, there was no evidence of audiology evaluation or replacement of the hearing aid, and an audiology consult was cancelled due to a language barrier. The DON confirmed the resident had not been seen by an audiologist and did not have hearing aids.
A resident with diabetes and multiple wounds had persistently elevated blood glucose levels despite repeated podiatry recommendations to maintain glucose below 180 mg/dL for wound healing. The facility did not notify the physician of these elevated levels or implement changes in nutritional or pharmacological interventions, and the podiatry recommendations were not addressed. The resident's condition worsened, resulting in hospitalization for wound infection and osteomyelitis.
Staff did not adhere to infection control protocols during wound care for two residents. In one case, staff performed wound care under Enhanced Barrier Precautions without wearing required PPE such as gowns and gloves. In another case, a nurse placed wound care supplies on a resident's bed, allowed saline to drip onto the bed, and failed to perform hand hygiene between glove changes.
A resident with severe cognitive impairment and multiple health conditions was found with a fractured lower leg of unknown origin. The facility conducted an internal investigation but did not report the injury to the State Survey Agency as required by policy and regulation. The DON confirmed the failure to submit the necessary report within the required timeframe.
Surveyors found that several resident rooms were not kept clean or sanitary, with used linens, overflowing trash, spills, stained privacy curtains, and unclean surfaces observed. Staff interviews revealed lapses in cleaning responsibilities between shifts.
The facility did not update PASRR Level II referrals for three residents who were newly diagnosed with serious mental illnesses such as Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, and Anxiety Disorder after their initial screenings indicated no need for further evaluation. Staff confirmed that required updates and referrals were not completed following these new diagnoses.
Surveyors identified that the facility did not develop care plans for two residents: one receiving oxygen therapy for pneumonia and another prescribed an antipsychotic for behavioral management. In both cases, the care plans lacked documentation addressing these treatments and monitoring for potential adverse effects, as confirmed by staff interviews and record reviews.
During a kitchen inspection, staff observed multiple opened food items—including spices, pasta, stuffing mix, and Parmesan cheese—stored without required labels or dates, and two sandwiches in the refrigerator also lacked labeling. These findings were confirmed by the Dietary Supervisor and were not in compliance with the facility's food storage policy.
Garbage and refuse were not properly disposed of as leaking commercial trash cans in the food service area caused liquid and food residue to spill onto floors and the loading dock, creating unsanitary and slippery conditions. Staff and the Administrator were aware of the issue for several weeks, but replacement trash cans had not yet been received.
Surveyors observed that staff failed to disinfect medical equipment between residents, did not use required PPE during care of residents on Enhanced Barrier Precautions, and improperly disposed of soiled gowns. In several instances, staff provided wound and catheter care without gloves or gowns, and a Foley catheter bag was found touching the floor.
A resident with multiple medical conditions was left exposed on a raised bed when both a nurse aide and an LPN exited the room simultaneously during wound care, at which time maintenance staff entered. This action failed to maintain the resident's dignity and privacy as required by facility policy.
A resident with a physician order and care plan specifying an 18 Fr Foley catheter was found to have a 14 Fr catheter in place. This discrepancy was confirmed by a nurse, indicating a failure to follow the prescribed incontinence management and catheter care.
Two residents did not receive supplemental oxygen at the flow rates ordered by their physicians. One resident with COPD and polyneuropathy received oxygen at a higher rate than ordered, while another with heart failure and atrial fibrillation received oxygen at a lower rate than ordered. These discrepancies were confirmed by a unit manager during observations.
A resident with a diagnosis of dementia was admitted without an individualized care plan addressing their dementia care needs. Review of the clinical record and care plan revealed no measurable goals or interventions for dementia care, and the DON confirmed that such residents should be care planned.
The facility failed to maintain dignity and privacy for five residents, as observed through untied gowns and exposed briefs. Residents expressed discomfort and inability to manage their clothing due to physical limitations. Staff left gowns untied for easier access, and one resident waited over an hour for assistance, with staff citing a lack of available personnel. All residents had their privacy compromised with open doors and curtains.
The facility did not offer or document influenza and pneumococcal vaccinations for ten residents, as required by their policy and regulations. Despite the infection control nurse's assurance to update records, no updates were made by the survey exit. This deficiency highlights a failure in adhering to vaccination protocols and documentation requirements.
A facility failed to assess a resident's ability to self-administer eye drops for glaucoma, as required by policy. The resident was found with multiple medications unsecured in her room, including one not listed in her physician orders. The unit manager confirmed no assessment was conducted to ensure the resident's capability to self-administer safely.
A resident with multiple medical conditions was moved to another room without prior written notice to her or her responsible party, following a complaint and threat from her roommate. The facility's policy requires written notification before room changes, which was not adhered to in this instance.
A resident with diabetes mellitus repeatedly refused prescribed insulin doses, but the facility failed to notify the physician as required by their medication administration policy. The resident refused a significant number of doses of Humalog and Levemir over two months, yet assessments by medical staff did not address these refusals, indicating a communication lapse.
The facility failed to update care plans for two residents, one with communication barriers and another with aggressive behavior. A resident with dementia and hearing loss had no updated interventions for communication in their care plan, despite language barriers. Another resident with dementia and aggressive behavior had multiple incidents of aggression documented, but their care plan lacked specific interventions to manage these behaviors.
A resident experienced significant weight fluctuations that were not timely addressed by the facility's staff. The dietician failed to verify the initial weight and did not document or respond to significant weight changes promptly. This led to a failure in maintaining the resident's nutritional status.
A resident with low back pain did not receive her prescribed Gabapentin on time, leading to unmanaged pain. The medication was scheduled to be administered three times daily, but a nurse confirmed it was delayed due to staffing shortages.
A facility failed to maintain accurate dialysis communication records for a resident with End-Stage Renal Disease. The resident's Hemodialysis Communication Record lacked pre-weight information before dialysis sessions, despite physician orders for regular treatment. The DON confirmed it was the nursing staff's responsibility to complete this paperwork.
A resident with a history of serious medical conditions expressed a desire to die after refusing hospital transport for chest pain. Despite this, the facility failed to assess her mental state or refer her for behavioral health services. The nurse practitioner was not informed of the resident's statement, and no documentation of an assessment or referral was made, indicating a deficiency in providing necessary behavioral health care.
A resident with diabetes was mistakenly given her roommate's medications, including glipizide, due to an LPN being distracted during administration. This resulted in the resident experiencing low blood sugar and requiring hospitalization for monitoring.
A resident with diabetes and hypertension was inaccurately documented by a nurse as having hypotension and mental status changes post-dialysis on three occasions. However, interviews with the Unit Manager and dialysis nurse confirmed no such changes occurred, highlighting a failure in maintaining accurate clinical records.
The facility failed to maintain an effective pest control program, with significant roach activity in the kitchen and laundry areas, and delayed bedbug treatment in a resident's room. Additionally, contaminated laundry was not properly bagged, potentially contributing to pest spread.
The facility did not maintain a clean and homelike environment on the Third Floor Nursing Unit, as evidenced by a persistent strong urine odor near a room. This was confirmed during observations by surveyors and acknowledged by the Nursing Home Administrator.
A resident and their representative reported grievances about not receiving the appropriate diet, including food that was easy to chew and double portions as ordered. Despite multiple reports, the facility failed to document or resolve these grievances. The facility's grievance policy was also found to be incomplete, lacking procedures for tracking and documenting grievances.
The facility did not report alleged neglect involving two residents to the State Survey Agency. One resident was left unattended in the bathroom, and her call bell was ignored, while another resident's family expressed dissatisfaction with care and decided to take the resident home. The facility's failure to report these incidents was confirmed by the Nursing Home Administrator.
A facility failed to thoroughly investigate a resident's care concerns, as required by its policies. The resident's family reported dissatisfaction with care, including call bell response time and male staff presence. The investigation lacked written statements from the resident or representative and included only partial staff interviews, despite multiple staff being on duty. The Director of Nursing confirmed the incomplete investigation.
Dignity Not Maintained During Care for a Blind Resident
Penalty
Summary
The facility did not ensure Resident R85’s dignity was maintained during care. Resident R85 was admitted in February 2023 with diabetic retinopathy and was legally blind. The clinical record also showed the resident was incontinent of bowel and had a care plan for staff assistance with activities of daily living because of blindness. Documentation dated August 7, 2025, stated the resident reported being hit in the face during care by nurse aide Employee E8. According to witness statements, the Assistant Director of Nursing and the unit manager heard Resident R85 yelling from the room and went to investigate. Resident R85 told the ADON that the nurse aide had hit her on the face. The nurse aide stated that after lowering the head of the bed, the resident said, "B***h I can't breathe," and the aide responded, "Don't speak to me like that you asked to be changed," after which the resident became louder and the aide walked out of the room. The resident later stated that staff needed to go slower and explain what they were about to do before doing it, and that the aide lowered the bed without asking first and she could not breathe.
Failure to Reduce Psychotropic Medication
Penalty
Summary
The facility failed to ensure that one resident received a gradual dose reduction of a psychotropic medication. Resident R193 had severe cognitive impairment and diagnoses of dementia, depression, and bipolar disorder. The resident’s quarterly MDS showed the resident was receiving antipsychotic and antidepressant medications, and the care plan identified the resident as at risk for behavior symptoms related to dementia and bipolar disorder. The care plan also included an intervention to attempt psychotropic drug reduction per physician orders. The resident had a physician order for Sertraline 25 mg daily for depression. A consultant pharmacist review dated December 8, 2025 recommended considering a gradual dose reduction for Sertraline, and the physician signed the report indicating agreement with the recommendation and to further consult psychiatry to adjust the dosage. However, the resident’s psychiatric exam was not conducted until March 20, 2026, and that exam recommended stopping Sertraline. The physician order for Sertraline remained active as of March 26, 2026, with no follow-up from the physician.
Failure to Develop Comprehensive Care Plans for Diabetes and Foley Catheter
Penalty
Summary
The facility failed to develop comprehensive care plans related to Diabetes Mellitus and an indwelling urinary catheter for two residents reviewed. One resident was admitted with diagnoses including Urinary Tract Infection and Essential Hypertension, and nursing evaluation documented an indwelling Foley catheter. The resident’s admission MDS coded an indwelling catheter as present, and physician orders directed catheter care every shift, securing the catheter with a secure device or tape, monitoring placement every shift, and changing the drainage bag as needed. However, the care plan for use of a urinary catheter was not initiated until March 5, 2025, and the care plan for risk for infection related to the indwelling Foley catheter was not initiated until March 21, 2026. The resident was observed on March 23, 2026, with a urinary catheter connected to a drainage bag. Another resident was alert and oriented and admitted with Type Diabetes Mellitus and bilateral proliferative diabetic retinopathy with macular edema. The resident was seen by an eye specialist approximately monthly and was instructed to sleep with the head of the bed elevated and avoid bending over at the waist. During interview, the resident stated she was not aware of those orders and only slept with the head of the bed elevated when short of breath. Review of the clinical record showed the facility failed to develop a care plan for the resident’s diagnosis of Type Diabetes Mellitus. The deficiency was confirmed by the Assistant Director of Nursing.
Failure to Address Abnormal Lab Results
Penalty
Summary
Facility did not ensure that treatment and care were provided in accordance with professional standards of practice related to abnormal laboratory values for one resident. Review of the resident’s clinical record showed a history of acute pulmonary edema, infection and inflammatory reaction due to an indwelling urethral catheter, epilepsy, hypotension, secondary malignant neoplasm of the breast, Down syndrome, and intellectual disability. The resident’s MDS indicated that the BIMS interview was not successful. Laboratory results collected on November 20, 2025 showed ACTH, Plasma = 5.0 (low) and Cortisol = 30 (high). A physician progress note entered on November 24, 2025 stated that the laboratory data suggested the possibility of adrenal adenoma, carcinoma, or primary adrenal hyperplasia causing the disparity in ACTH and cortisol levels, and that due to the resident’s underlying cognitive impairment from Down syndrome, the physician was reluctant to pursue diagnostic procedures and would continue to monitor status. The record contained no further explanation of what the resident was to be monitored for and no documented nursing interventions showing steps taken to prevent complications after the abnormal laboratory results.
Nephrostomy Bags Not Draining by Gravity
Penalty
Summary
The facility failed to ensure that a resident’s nephrostomy urine bags were draining by gravity. Resident R17 was admitted with chronic kidney disease and had physician orders for left nephrostomy output to be monitored and recorded every shift, right nephrostomy output to be monitored and recorded every shift, and nephrostomy drain care with monitoring and changing every shift and as needed. The facility policy on nephrostomy care stated that the nephrostomy tube should be placed below the level of the kidneys and that if resistance occurred during irrigation, the nephrostomy tube should be reattached to the drainage tube and allowed to drain by gravity. During observation, Resident R17 was found lying flat on the bed with both the left and right nephrostomy bags also lying flat on the bed. Resident R17 stated that staff always placed the nephrostomy bags on the bed and never hung them under the bed. The Assistant Director of Nursing confirmed that both nephrostomy bags were lying flat on the bed at the time of observation.
Failure to Maintain Resident Nutrition and Weight Monitoring
Penalty
Summary
The facility failed to identify, implement, monitor, and modify interventions to maintain acceptable nutrition parameters for Resident R173 and Resident R282. Resident R173 had severe cognitive impairment, dementia, dysphagia, muscle weakness, and muscle wasting. The resident’s MDS indicated significant weight loss and difficulty swallowing, including holding food in the mouth/cheeks after meals. The clinical record showed weights of 120 pounds on 10/18/2025, 110.8 pounds on 10/19/2025, 100.2 pounds on 10/22/2025, 95.8 pounds on 11/5/2025, and 97.8 pounds on 11/18/2025, reflecting a 16.5% weight loss from 10/18/2025 to 10/22/2025. The significant weight loss was not addressed until 10/30/2025. A nutrition assessment was documented but not signed and completed until 11/19/2025, and although it noted probable weight loss due to cognitive impairment, dysphagia, and increased calorie and protein needs for wound healing, it did not identify the type or frequency of supplements recommended.
Medication Storage Room Temperature Out of Range
Penalty
Summary
Drugs and biologicals were not stored according to professional standards of practice in one of two medication storage rooms reviewed on the 4th floor unit, specifically the medication storage room on 4 South. Facility policy titled "Medication storage," effective March 2020, stated that all drugs and biologicals were to be stored in a safe, secure, and orderly manner. On March 26, 2026, the ambient temperature in the medication storage room was observed at 80 F, which exceeded the generally accepted controlled room temperature range of 68 F to 77 F. During the medication room inspection at 9:30 AM, 15 medications were found stored at temperatures above recommended limits. During a later observation at 11:40 AM, multiple OTC medications were also observed stored in the same room where the ambient temperature remained above the manufacturer-recommended storage range. The unit manager confirmed at 11:45 AM that the room temperature was 80 F and that there was no evidence of prior documented room temperature logs. The medications observed included 0.9% sodium chloride injections, lidocaine relief gel patches, acetaminophen 325 mg, nicotine transdermal patches, muscle rub cream, nasal moisturizing spray, omeprazole 20 mg, sevelamer carbonate tablets, hemorrhoidal ointment, zinc 50 mg, vitamin D3, docusate sodium soft gels, fish liver oil, glucose gel, and loperamide tablets.
Delayed Review of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure laboratory values were timely reviewed for one resident with severe cognitive impairment and a diagnosis of dementia. After the resident had an episode of apparent seizure-like activity lasting approximately three minutes, the physician was notified and ordered a panel of labs. The labs were drawn and resulted the same day, and ten lab values were documented as out of range. However, the clinical record contained no documented evidence that the physician reviewed or followed up on the lab results, and a nurse confirmed there was no evidence the labs were discussed with and reviewed by the physician.
Modified Diet Not Followed for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that Resident R215 received a modified diet consistent with assessed needs. The resident had severe cognitive impairment and diagnoses of dementia, malnutrition, and dysphagia. Facility records showed the resident was assessed for a mechanically altered diet, and speech therapy discharge documentation recommended a puree consistency diet because the resident pocketed ground and chopped textures, was unable to follow directions, had difficulty clearing pocketed food with liquids, and on multiple occasions required the speech therapist to physically remove food from the oral cavity. A physician order also specified a pureed textured diet consistency. During lunch observation in the 3 Floor dining room, Resident R215 was seated with a plate of pureed food in front of him/her but was eating a piece of regular cake with his/her hands. The meal ticket on the tray indicated a pureed diet order. When interviewed at the time of the observation, the LPN stated the resident was allowed to have the cake despite the meal ticket specifying pureed texture diet consistency. The speech therapist confirmed the resident was ordered a puree textured diet consistency without any exceptions or modifications.
Resident Elopement Due to Inadequate Supervision and Elopement Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with dementia, muscle weakness, and major depressive disorder was able to exit a secure, third-floor lockdown unit without staff knowledge. The resident's care plan identified them as at risk for falls and noted impaired cognitive function, but an elopement evaluation was inaccurately coded, failing to identify the resident as cognitively impaired or at risk for elopement. As a result, the resident was not care planned for elopement risk, and no additional supervision or interventions were implemented to prevent unauthorized exit. On the day of the incident, the resident was last seen in bed by staff and subsequently left the secure unit by following dietary staff into the elevator. The dietary staff did not recognize the resident as a resident, and the front desk receptionist, also failing to identify the individual as a resident due to their attire and lack of identification, allowed them to exit the facility. The absence of a process for signing out visitors further contributed to the failure to recognize the resident's departure. The facility only became aware of the resident's absence when a family member called to report that the resident had arrived at their home, which was 1.2 miles away and required crossing busy streets and high-traffic areas. The resident was missing for approximately two hours before being returned to the facility. This sequence of events demonstrated a lack of adequate supervision and failure to maintain a secure environment for residents at risk, resulting in an Immediate Jeopardy situation.
Removal Plan
- Resident was assessed by the nursing supervisor and no concerns were noted.
- Resident was provided with an anti-elopement device and was placed on a one-to-one observation by staff until seen by Geri-Psych Nurse Practitioner.
- Nurses reviewed or completed an elopement evaluation for all current residents.
- All residents who were deemed high risk for elopement were also provided with an anti-elopement device and care planned.
- Facility Elopement Policy was updated by Administration to include how the facility will identify residents who are at risk for elopement.
- New process was put in place for the front desk staff to oversee the completion of entrance logs for visitors and staff.
- Kitchen staff started a new process to not allow residents and visitors in facility elevators when in use for dietary functions.
- Elopement drills were completed.
- Facility staff were educated on the updated elopement process.
- Facility staff were educated prior to the start of their shifts with any per diem, part time, or agency staff education to occur before their next shift.
- Director of Nursing or designee will complete an audit of resident's charts to ensure residents who are at risk for elopement have an elopement evaluation completed. The audit will be conducted twice a week for 30 days.
- Results of the audit will be presented to the monthly QAPI committee for review.
Failure to Supervise Results in Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure adequate supervision for a resident with dementia, muscle weakness, and major depressive disorder. The resident was admitted to a locked unit and was identified as being at risk for falls and impaired cognitive function. Despite these known risks, staff were unaware of any elopement history for the resident, and there was no process in place to sign out visitors, which contributed to the lack of oversight. On the day of the incident, the resident was last seen in bed and was able to leave the locked unit with the assistance of dietary staff, who did not recognize the individual as a resident. The resident then used the elevator to reach the first floor. At the front entrance, the receptionist mistook the resident for a visitor due to their attire and lack of identifying medical bands, and allowed them to exit the facility. Staff only became aware of the resident's absence after receiving a call from the resident's family member. The resident was located approximately two hours later, 1.2 miles away from the facility, after having accessed high traffic areas and busy intersections. The investigation revealed that the facility's failure to provide adequate supervision and to implement effective processes for monitoring residents and visitors directly contributed to the resident's unsupervised exit. This incident was identified as an Immediate Jeopardy situation due to the high risk for injury.
Inaccurate Elopement Risk Assessment for Resident with Dementia
Penalty
Summary
The facility failed to ensure the accuracy of an elopement risk assessment for one resident. Clinical record review showed that the resident was admitted with diagnoses including dementia, muscle weakness, and major depressive disorder. Despite documentation in the care plan indicating impaired cognitive function due to dementia, the elopement evaluation inaccurately coded the resident as not cognitively impaired and not at risk for elopement. Staff interview confirmed that elopement assessments should consider the resident's decision-making ability and any relevant diagnoses or behaviors, which was not reflected in the assessment reviewed.
Failure to Implement Podiatry Recommendations and Manage Blood Glucose for Wound Healing
Penalty
Summary
The facility failed to implement podiatry recommendations for wound care and diabetic management for a resident with multiple risk factors, including diabetes, peripheral vascular disease, decreased mobility, and existing wounds to the foot and heel. Despite repeated podiatry consults recommending specific wound care protocols and maintaining blood glucose levels below 180 mg/dl to promote healing, the facility did not follow through with these recommendations. Clinical records showed that the resident's blood glucose levels were consistently above the recommended range, with 39 out of 43 entries exceeding 180 mg/dl after the recommendations were made. There was no documented evidence that the physician was notified of the resident's persistently elevated blood glucose levels, nor were there any documented attempts to modify nutritional or pharmacological interventions to address the issue. The resident's condition worsened, resulting in a wound infection and subsequent hospital admission for osteomyelitis. The Director of Nursing confirmed that the podiatry recommendations for diabetic management were not addressed and that staff did not notify the physician of the elevated blood sugar levels.
Failure to Provide Hearing Services and Replace Lost Hearing Aid
Penalty
Summary
The facility failed to provide appropriate services to promote and maintain hearing abilities for a resident with documented moderate hearing difficulty. The resident's Minimum Data Set (MDS) indicated the use of a hearing aid, but interviews and record reviews revealed that the hearing aid was missing shortly after admission and was not replaced. The resident's representative reported ongoing difficulty with hearing and confirmed that the resident had not been seen by an audiologist, nor was there evidence in the clinical record of a scheduled audiology visit to address the hearing impairment or replace the lost hearing aid. Further review of the care plan showed interventions for communication problems related to hearing loss, including the use of hearing aids and communication devices. However, there was no documentation of follow-through on these interventions. An audiology consult was scheduled but later cancelled, with a note indicating a language barrier as the resident primarily spoke Italian. The Director of Nursing confirmed that the resident had not been evaluated by an audiologist and did not have hearing aids at the time of the survey.
Failure to Address Diabetic Management and Physician Notification for Wound Healing
Penalty
Summary
The facility failed to ensure that a physician assessment was completed and that changes in medical status were addressed in accordance with professional standards of practice for diabetic management to promote wound healing for a resident with diabetes and multiple wounds. The resident's care plan identified risks related to decreased mobility, incontinence, aged skin, peripheral vascular disease, and a history of diabetes. Despite repeated podiatry consults recommending blood glucose control below 180 mg/dL to promote wound healing, the resident's blood glucose levels were consistently elevated, with 39 out of 43 readings above the recommended threshold. Physician orders required notification for blood glucose levels below 70 or above 250, but the majority of readings were above 180, and several exceeded 250. There was no documented evidence that the physician was notified of the persistently elevated blood glucose levels, nor that any nutritional or pharmacological interventions were attempted or modified to address the hyperglycemia. The podiatry recommendations for optimal diabetic management were not addressed by the physician, and the resident's wounds worsened, ultimately resulting in hospitalization for wound infection and osteomyelitis. The Director of Nursing confirmed that the podiatry recommendations for diabetic management to promote wound healing were not addressed.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols during wound care for two residents. In one instance, a Licensed Practical Nurse and a Nurse Aide provided wound care to a resident who was under Enhanced Barrier Precautions (EBP), as indicated by a sign on the resident's door, but neither staff member wore a gown or gloves during the procedure. This was confirmed by a licensed nurse during an interview. In another instance, a licensed nurse placed wound care supplies, including gloves, gauze, saline, border dressing, and medication, directly on the resident's bed at the foot of the bed. During the procedure, saline was observed dripping from the gauze onto the bed. The nurse removed used gloves and applied new gloves that had been placed on the bed, without performing hand hygiene between glove changes. These actions were not in accordance with facility policy or CDC guidelines for infection prevention and control.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with severe cognitive impairment and multiple medical conditions, including atrial fibrillation, muscle wasting, and chronic kidney disease, was found with pain, redness, and swelling in the right lower extremity. Subsequent assessment and a stat x-ray revealed a fracture, and the resident was transferred to the emergency department per physician order. The facility initiated an internal investigation, which included review of witness statements, but no staff reported witnessing the injury or any change in the resident's condition prior to the complaint of pain. Despite the facility's policy requiring the reporting of all alleged violations involving mistreatment, neglect, or abuse—including injuries of unknown origin—to the Department of Health and other relevant agencies, there was no evidence that the injury was reported to the State Survey Agency. The Director of Nursing confirmed that the required report was not submitted within the mandated timeframe, resulting in noncompliance with state regulations regarding the timely reporting of suspected abuse, neglect, or injury of unknown origin.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, sanitary, and homelike environment in five resident rooms. Specific findings included used wash cloths on the floor, unemptied trash bins, overflowing trash, excess trash on the floor, liquid spills, trash under beds, food crumbs, unclean bedside tables, and used portable urinals left on the floor. Additionally, a privacy curtain was found with large yellow and white stains, walls had multiple brown stains, and an air conditioner vent cover had visible brown spills. Two empty medication cups were also observed in a resident's room. Staff interviews indicated that cleaning responsibilities were not consistently fulfilled between shifts.
Failure to Update PASRR Level II Referrals for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental disorders for a Level II Pre-Admission Screening and Resident Review (PASRR) as required. Clinical record reviews and staff interviews revealed that three residents with diagnoses such as Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, and Anxiety Disorder did not have updated PASRR Level II evaluations completed after these diagnoses were made. The original PASRR forms for these residents indicated negative screens for serious mental illness, and no further evaluation was deemed necessary at the time, despite subsequent diagnoses that should have triggered a Level II referral. Specifically, one resident was diagnosed with Schizoaffective Disorder, Bipolar Type, and Major Depressive Disorder after the initial PASRR screening, but the PASRR was not updated. Another resident had diagnoses of Schizoaffective Disorder, Anxiety Disorder, and Major Depressive Disorder entered after the initial negative PASRR screening, with no update or referral for Level II evaluation. A third resident was admitted with physical health conditions, but later received diagnoses of psychosis, major depressive disorder, and anxiety disorder, again without an updated PASRR. Staff interviews confirmed that the required updates and referrals were not completed as mandated.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Antipsychotic Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents regarding their specific clinical needs. For one resident with chronic obstructive pulmonary disease and polyneuropathy, a physician order was in place for oxygen therapy due to pneumonia, but the comprehensive care plan did not address the use of oxygen therapy. This omission was confirmed by the unit manager during an interview. For another resident with diagnoses of dementia, depression, and breast cancer, a physician order was present for the administration of Rexulti, an antipsychotic medication, to manage behaviors. However, the care plan did not include any information regarding the use of the antipsychotic medication or monitoring for potential adverse reactions. The Director of Nursing confirmed that no care plan had been developed for the antipsychotic use. These findings were based on observations, staff interviews, and review of clinical records and policies.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple observations during a kitchen tour with the Dietary Supervisor. Various opened spices, including ground cinnamon, chicken herb, Italian seasoning, and poultry seasoning, were found on the preparation table without dates. An opened container of Parmesan cheese, which per manufacturer instructions requires refrigeration after opening, was stored with the spices and lacked both a label and date. In the dry storage room, three bags of opened pasta and a traditional stuffing mix seasoning were also found without labels or dates. Additionally, two sandwiches in the walk-in refrigerator were observed on a tray without labels or dates. All these observations were confirmed by the Dietary Supervisor, and the facility's policy requires all refrigerated or frozen foods to be covered, labeled, and dated.
Improper Disposal of Garbage Due to Leaking Trash Cans
Penalty
Summary
Garbage and refuse were not disposed of properly in the facility's Food Service Department, as evidenced by observations of leaking 96-gallon commercial trash cans. During a tour, a trash can was seen leaking significant amounts of yellow and brown liquid while being moved from the dishwasher area to the loading dock, and staff were observed cleaning residue from the cement near the dumpster. On a subsequent day, two trash cans were actively leaking, with one in use near the dishwasher and another at the loading dock, resulting in trails of spilled food and a puddle of white and yellow residue that created a slippery surface. The Dietary Supervisor confirmed these observations, and the Administrator acknowledged being aware of the broken trash cans for several weeks, stating that replacement orders had not been fulfilled by the supplier.
Failure to Follow Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control program, specifically regarding the cleaning of medical equipment and adherence to Enhanced Barrier Precautions (EBP). During medication administration, a licensed nurse used a sphygmomanometer on multiple residents without disinfecting it between uses. Additionally, a nurse applied a nicotine patch, checked oxygen saturation, and changed oxygen tubing for a resident with a known MRSA infection without wearing the required PPE, despite the resident being on EBP. These actions were confirmed by staff present at the time. Further deficiencies were observed during wound care and hygiene activities. A licensed nurse failed to properly dispose of a used gown after wound treatment for a resident on EBP, leaving it on a PPE cart intended for clean items. Another resident with a Foley catheter had the catheter bag touching the floor, and both a nurse aide and a licensed nurse provided hygiene and wound care to this resident without wearing PPE. The facility's policies required the use of PPE and proper cleaning of reusable equipment, but these protocols were not followed as observed.
Resident Left Exposed During Wound Care
Penalty
Summary
Facility staff failed to ensure resident dignity during wound care treatment for one resident. During hygiene and wound care, both a nurse aide and a licensed nurse left the resident's room at the same time, leaving the resident exposed on a raised bed. While the resident was left unattended and exposed, a maintenance staff member entered the room. The resident's care plan indicated the bed should be in the lowest position when care is not being provided, and facility policy required staff to maintain and protect resident privacy, including bodily privacy during treatment procedures. The resident involved had a medical history including unspecified intellectual disabilities, a non-pressure chronic ulcer of the back, muscle wasting and atrophy, orthostatic hypotension, and heart failure.
Failure to Follow Physician Order for Foley Catheter Size
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to implement appropriate treatment and services for incontinence management for one resident. Specifically, the physician's order for the resident indicated the use of a Foley catheter sized 18 French (Fr) with a 60 cc sterile saline irrigation as needed for blockage. The resident's care plan also documented the use of an 18 Fr Foley catheter. However, during an observation, it was found that the resident had a Foley catheter of size 14 Fr with a 30 cc balloon in place, which did not match the physician's order or the care plan. This discrepancy was confirmed at the time of observation with a licensed nurse. The failure to provide the correct catheter size as ordered by the physician constituted a deficiency in the facility's incontinence management and nursing services.
Failure to Administer Supplemental Oxygen as Ordered
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two residents. For one resident with chronic obstructive pulmonary disease and polyneuropathy, the physician ordered oxygen at 2 liters per minute via nasal cannula. However, during observation, the oxygen was set at 3 liters per minute. The unit manager confirmed the discrepancy and noted that the setting should have been 2 liters, while the resident denied changing the oxygen setting. For another resident with acute on chronic diastolic heart failure and chronic atrial fibrillation, the physician ordered oxygen at 3 liters per minute via nasal cannula. Observation revealed that the oxygen was set at 2 liters per minute. The unit manager confirmed this observation. These findings indicate that the facility did not follow its own policy and physician orders regarding oxygen administration for these residents.
Failure to Develop and Implement Dementia Care Plan
Penalty
Summary
A resident admitted with a diagnosis of dementia did not have an individualized, person-centered care plan developed or implemented to address their dementia care needs. Review of the resident's clinical record and care plan dated March 13, 2025, showed no measurable goals or interventions related to dementia care. During an interview, the Director of Nursing confirmed that residents diagnosed with dementia should have a care plan in place. This deficiency was identified for one of 35 residents reviewed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain personal dignity for five residents, as evidenced by observations and interviews. Resident R1, with moderately impaired cognition, was found with her gown untied and partially exposing her chest, causing her discomfort and distress. She expressed her inability to tie the gown due to limited range of motion, and staff left it untied for easier access to her sling. Similarly, Resident R2 was observed with her gown untied, exposing her back and brief, and she expressed a desire for her gown to be tied, which she could not do herself. Resident R3 was found with her gown untied and brief exposed, while Resident R4 had his gown above his waist, exposing his brief, with personal care items left on a table beside his bed. Resident R5, with intact cognition, was observed with his undergarment pulled down and brief exposed, waiting for over an hour for assistance to pull up his undergarments and be transferred to his wheelchair. An employee acknowledged the delay, citing a lack of available staff for the required two-person assist. All residents had their doors and privacy curtains open, compromising their privacy and dignity. These observations and interviews indicate a failure to uphold the facility's policy on resident dignity, which mandates respect for residents' private space and bodily privacy during care.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to maintain personal dignity for all residents. 1. R1, R2, R3, R4, and R5 were immediately provided privacy. 2. Resident care areas were checked to ensure privacy and were in compliance. 3. Education was completed with nursing staff to maintain and protect resident privacy, including bodily privacy. Unit managers will routinely check resident care areas to ensure nursing staff are maintaining and protecting their privacy. 4. The Director of Nursing or designee will complete an audit once a week for one month to ensure residents are receiving privacy, including bodily privacy. Results of audits will be reviewed at the facility QAPI meeting.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to offer or provide influenza and pneumococcal vaccinations to ten residents, as determined by a review of clinical records and staff interviews. The facility's policy, dated November 2018, mandates that all residents without medical contraindications be offered the influenza vaccine annually, with proper documentation of the vaccination or refusal in the resident's medical record. However, the records for residents R15, R36, R39, R73, R110, R111, R190, R204, R228, and R231 showed no evidence of receiving or being offered these vaccines. The infection control nurse, Employee E16, confirmed the absence of documentation for the vaccines and believed the information was located elsewhere, promising to update the records. Despite this, by the time of the survey exit on June 17, 2024, the records had not been updated. The facility's failure to document or offer the vaccines is a violation of the regulations requiring pneumococcal immunization offers and proper documentation, as well as the facility's own policy.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the clinical appropriateness of self-administering medication. The facility's policy requires an assessment of the resident's mental and physical abilities, comprehension of medication instructions, and safe storage of medications. However, there was no evidence of such an assessment for the resident, who was self-administering eye drops for glaucoma treatment. The resident's physician orders included instructions for self-administration of one medication, but not for another, and the resident was found to be keeping multiple medications, including an over-the-counter product, unsecured in her room. During an observation, the resident was seen with a sandwich bag containing three bottles of eye medication, including Combigan and Latanoprost, as well as Systane, which was not listed in her physician orders. The resident confirmed that she self-administers these medications and stores them in her room. An interview with the unit manager confirmed that no assessment had been conducted to determine the resident's capability to self-administer the medications safely, as required by the facility's policy.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice to a resident and her responsible party before a room change was made. This deficiency was identified for one resident, who was moved to another room without prior written notification. The facility's policy requires that residents and their roommates be notified of the reason for a room change before it occurs. However, in this case, the resident was moved during the night shift after her roommate complained about her behavior, without any written notice being given to the resident or her responsible party. The resident involved had multiple medical conditions, including dysphagia, respiratory failure, dementia, anxiety, hypertension, and COPD, and was cognitively impaired. The room change occurred after the roommate expressed distress and threatened violence if the resident was not moved. The nursing staff moved the resident to another room during the night shift, but there was no documentation of written notice being provided to the resident or her responsible party, as required by the facility's policy.
Failure to Notify Physician of Insulin Refusal
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal to take prescribed insulin medications, which is a violation of their policy on administering medications. The policy requires that medications be administered safely, timely, and as prescribed, and that any concerns, such as medication refusals, be reported to the doctor. Resident R108, who is cognitively intact and diagnosed with diabetes mellitus, was prescribed Humalog and Levemir insulin injections. However, the resident refused a significant number of these doses over the months of May and June 2024. Specifically, Resident R108 refused 21 out of 31 doses of Levemir and 58 out of 93 doses of Humalog in May 2024, and 10 out of 13 doses of Levemir and 24 out of 39 doses of Humalog in June 2024. Despite these frequent refusals, there was no documented evidence that the physician was informed. Assessments by a physician and a nurse practitioner during this period did not address the refusals, indicating a lack of communication regarding the resident's non-compliance with the prescribed insulin regimen.
Deficiencies in Care Plan Updates for Communication and Behavior Management
Penalty
Summary
The facility failed to ensure that resident care plans were reviewed and revised to reflect the residents' status and care needs related to communication and aggressive behavior for two residents. Resident R507, who was admitted with dementia, renal deficiency, and hypertension, has a communication barrier due to a hearing deficit and a preference for speaking Spanish. Despite these challenges, the resident's care plan did not include updated interventions or goals related to speech and language, nor did it address the communication barrier adequately. Interviews with staff and the resident's family representative revealed discrepancies in the resident's language abilities, indicating a lack of accurate assessment and documentation in the care plan. Resident R205, admitted with dementia, anxiety, depression, hypertension, renal insufficiency, and diabetes, exhibited aggressive and agitated behaviors. The resident's care plan identified a risk for behavior symptoms related to dementia and language barriers but did not include an updated assessment or plan to address the resident's abusive behavior. The resident's clinical records documented multiple incidents of physical aggression towards other residents and visitors, yet the care plan lacked specific interventions to manage these behaviors effectively.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident R112, due to improper weight monitoring and documentation. The resident was admitted with a recorded weight of 152 lbs, which was later questioned by the dietician and changed to 171.2 lbs based on a re-weight and the resident's input. However, the dietician did not verify the accuracy of the initial weight or ensure that the correct admission weight was used for monitoring the resident's nutritional status. Significant weight fluctuations were recorded for the resident, including a 28.1% weight gain from January to February and a 41.7% weight loss from February to March. These changes were not addressed in a timely manner by the nursing staff or the dietician. The dietician did not document any actions taken to address the significant weight gain until 14 days after it was recorded, and a re-weight was not obtained until 21 days later. Similarly, the significant weight loss was not acknowledged or addressed promptly, with a re-weight only obtained 8 days after the initial recording. Further weight loss was recorded in April and June, with no evidence of timely intervention or re-weight requests by the dietician. The dietician confirmed during interviews that the significant weight changes were not addressed or documented appropriately, and re-weights were not requested or obtained in a timely manner. This lack of timely response and documentation led to the failure in maintaining the resident's nutritional status.
Failure in Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R71, consistent with professional standards of practice. The resident, who was admitted with diagnoses including low back pain and complications from cardiac and vascular devices, reported not receiving her pain medication, Gabapentin, on the morning of June 17, 2024, and experiencing significant back pain. The physician's order required Gabapentin to be administered three times daily at specific times. However, the Medication Administration Records indicated that the medication was not given as prescribed and was administered more than one hour after the scheduled time. A licensed nurse, identified as Employee E7, confirmed the delay, citing being short-staffed as the reason for not administering the medication on time.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident diagnosed with End-Stage Renal Disease, who was admitted to the facility and required regular dialysis treatment. The physician's order specified that the resident should receive dialysis treatment in the facility from Monday through Friday. However, a review of the resident's Hemodialysis Communication Record from May 24, 2024, through June 14, 2024, revealed missing information on the resident's pre-weight before going to dialysis. The top part of each communication record indicated that it was for nursing home use only prior to dialysis. An interview with the Director of Nursing confirmed that it was the nursing staff's responsibility to complete the paperwork for residents before they went to dialysis.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident who expressed a desire to die. The resident, identified as R606, had a medical history that included an aortic aneurism, hypertension, epilepsy, and glaucoma. On May 28, 2024, the resident experienced chest pain and was administered Nitrostat, which did not alleviate the pain. When Emergency Medical Services arrived, the resident refused to go to the hospital and expressed a wish to die. Despite this significant statement, there was no evidence in the clinical records that the nursing staff assessed the resident's mental state or explored the reasons behind her statement. Additionally, there was no documentation indicating that the resident was referred for psychiatric or counseling services to address potential behavioral health needs. The resident was seen by a nurse practitioner the following day, but there was no documentation that the nurse practitioner was informed of the resident's statement about wanting to die. The progress notes from the nurse practitioner only mentioned the resident's chest pain and her refusal for further testing, without addressing the behavioral health concern. During an interview with the Unit Manager, it was confirmed that there was no documentation of an assessment or referral for behavioral health services following the resident's concerning statement. This lack of action and documentation represents a deficiency in the facility's provision of necessary behavioral health care and services.
Significant Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident R174. The resident, who was diagnosed with Diabetes Mellitus, high blood pressure, and unspecified intellectual disabilities, was mistakenly given her roommate's medications. This error occurred despite the facility's policy requiring the verification of the five rights of medication administration: right resident, right time and frequency, right dose, right route, and right drug. On the day of the incident, Resident R174 received her prescribed dose of metformin and, two hours later, was erroneously administered her roommate's medications, including glipizide, which is also used to treat high blood sugar levels. The error was identified when the resident began feeling light-headed and dizzy, prompting a nurse practitioner to order her transfer to the emergency room. Upon arrival, her blood glucose level was found to be 67 mg/dL, which is below the normal fasting range. The resident was admitted to the ICU for close monitoring of her blood glucose levels, which remained stable, allowing her to be downgraded to a medical/surgical floor before being discharged back to the facility. The LPN responsible for the error admitted to being distracted during medication administration, which led to the mistake.
Inaccurate Documentation of Resident's Post-Dialysis Condition
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident, identified as R98, who had a medical history of diabetes, hypertension, and dependence on renal dialysis. The deficiency was identified through interviews and clinical record reviews, which revealed discrepancies in the documentation of the resident's condition post-dialysis. Specifically, on three consecutive days, a licensed nurse, Employee E12, documented that the resident returned from in-house dialysis with hypotension and a change in mental status. However, there was no additional information, monitoring, or physician notification related to these documented changes in the resident's health status. Further investigation, including interviews with the 4th floor Unit Manager and the dialysis nurse, revealed that the resident completed dialysis treatments on those days without any reported changes in blood pressure or mental status. The Unit Manager and dialysis nurse both confirmed that there were no concerns with the resident's condition, contradicting the documentation by Employee E12. The facility was unable to provide an explanation for the inaccurate documentation, leading to the identification of this deficiency.
Pest Control and Laundry Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports of roach activity in the main kitchen and laundry areas. Initial pest control reports indicated significant roach activity behind the wall covering by the steamers in the kitchen, with recommendations for a clean-out. However, the administration opted for conventional treatments first, delaying the recommended clean-out until several months later. Observations revealed that the kitchen's door sweep was not completely sealed, allowing pests easy access, and a live cockroach was seen behind the steam tables. In addition to the issues in the kitchen and laundry, the facility also failed to address bedbug activity in a resident's room promptly. The pest control management service identified bedbugs during a routine inspection, but the initial treatment was delayed until the sighting was confirmed. This delay resulted in multiple treatments over several weeks, with live bedbug activity still observed during subsequent inspections. The administrator was unaware of the original sighting, contributing to the delay in treatment. Furthermore, the facility's laundry services were found to be inadequate, as contaminated textiles and fabrics were not properly bagged. During a tour of the laundry room, it was observed that laundry from the chute was loose and unwrapped, which was confirmed by the maintenance director. This failure to properly contain contaminated laundry could contribute to the spread of pests and other microorganisms within the facility.
Failure to Maintain Clean Environment on Third Floor
Penalty
Summary
The facility failed to provide a clean and homelike environment on the Third Floor Nursing Unit, specifically in the area designated as 3-North. During an observation on May 16, 2024, at approximately 11:00 a.m., a strong odor of urine was detected near a specific room. A follow-up observation conducted later that day at 2:10 p.m., with the Nursing Home Administrator present, confirmed that the strong urine odor was still noticeable in the same area. The Nursing Home Administrator acknowledged the presence of the odor, indicating a deficiency in maintaining a clean and comfortable environment for residents.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to properly document and resolve a grievance reported by a resident and their representative. The grievance involved the resident not receiving the appropriate diet, specifically not being provided with food that was easy to chew and not receiving the ordered double portions. Despite the resident and their representative reporting these concerns multiple times to the facility staff, the issues were not resolved, nor was there any documented response from the facility. Interviews with the facility administrator and a nursing unit coordinator confirmed that the grievance was not documented, and the facility only initiated written grievances when issues could not be addressed quickly. Additionally, the facility's grievance policy was found to be lacking in required components. The policy did not include procedures for tracking all grievances, documenting grievance decisions, or providing summary statements of all grievances. The administrator confirmed that the existing policy was the only one available related to the grievance process, indicating a systemic issue in handling grievances. This deficiency was identified during a review of clinical records, facility documentation, and interviews with residents and staff.
Failure to Report Alleged Resident Neglect
Penalty
Summary
The facility failed to report alleged violations of resident neglect to the State Survey Agency as required. The facility's policy mandates that all alleged violations involving mistreatment, neglect, or abuse must be reported to the Department of Health and other relevant agencies. However, in the cases of two residents, this protocol was not followed. Resident R1 reported that a nurse aide did not assist her while she was in the bathroom, and her call bell was not answered in a timely manner. The resident's representative confirmed that staff did not provide care and that she had to come to the facility in the middle of the night to assist the resident. Similarly, Resident R2's daughter expressed concerns about the care provided, including dissatisfaction with weekend care, call bell response time, and the presence of male staff. The social worker and dietician documented the family's dissatisfaction with the overnight care, and the family decided to take the resident home. Despite these grievances, the facility did not report the allegations to the State Survey Agency, as confirmed by the Nursing Home Administrator.
Incomplete Investigation of Resident Care Concerns
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of improper resident care for one resident. The deficiency was identified through a review of clinical records, facility policies, and staff interviews. The facility's policy on abuse prevention and reporting requires immediate investigation of all claims, including obtaining written statements from residents or their representatives, and conducting interviews with all relevant staff. However, in this case, there was no documented evidence that the facility obtained written statements from the resident or their representative regarding the specifics of the allegations. Additionally, the investigation included only four staff interviews and one supervisor statement, despite there being eight nurses' aides and multiple LPNs working on the unit during the relevant time period. The deficiency was further highlighted by the grievance filed by the resident's daughter, who reported concerns about the care provided, including dissatisfaction with weekend care, call bell response time, and the presence of male staff in the resident's room. The social worker's statement confirmed that the family was unhappy with the care provided during specific shifts, and the dietician's statement indicated that the family intended to take the resident home due to dissatisfaction with overnight care. The Director of Nursing confirmed that the facility did not obtain witness statements from all staff who worked on the unit, which is a requirement under the facility's policy and state regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitional Care Unit At Nazareth Hospital | 0.8 mi | ★★★★★ | 0 | 0 |
| Deer Meadows Rehabilitation Center | 0.8 mi | ★★★★★ | 21 | 0 |
| Wesley Enhanced Living Pennypack Park | 0.8 mi | ★★★★★ | 11 | 0 |
| The Pines At Philadelphia Rehab And Healthcare Ctr | 0.9 mi | ★★★★★ | 1 | 0 |
| Roosevelt Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 24 | 0 |
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