Letort Spring Nursing And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Pennsylvania.
- Location
- 801 N. Hanover Street, Carlisle, Pennsylvania 17013
- CMS Provider Number
- 395784
- Inspections on file
- 26
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Letort Spring Nursing And Rehab Llc during CMS and state inspections, most recent first.
A resident with a history of deep vein thrombosis and dementia was ordered warfarin 2.5 mg at bedtime with a PT/INR recheck. The resident received warfarin as ordered initially, but then went several days without the medication and without the scheduled PT/INR because the staff member entering the orders signed off the lab in a way that prevented it from populating and set the warfarin order to stop on the lab date. The missed doses and omitted lab were later identified by nursing staff and brought to the provider’s attention.
The facility failed to follow its own food safety and sanitation policies in the kitchen, nourishment rooms, and during tray service. Surveyors found extensive cleanliness problems, including residue and dust on the ice machine, soiled shelving and drawers under the coffee maker, food debris on floors and under equipment, heavily soiled stoves and floors, and dirty dish room walls. Multiple opened food and beverage items in refrigerators, freezers, and dry storage lacked labels, open dates, discard dates, or resident identification, and some prepared foods were past their discard dates or improperly wrapped. Nourishment refrigerators on two wings contained undated thickened liquids and supplements, unlabeled resident food items, and one lacked a temperature log and freezer thermometer. Staff sanitary practices were deficient: a Dietary Manager handled expired hand sanitizer bottles and returned to food preparation without changing gloves, and a dietary aide on tray line repeatedly touched ready-to-eat foods with gloved hands while also handling meal tickets and the lid of a soiled linen hamper without changing gloves or washing hands. During tray pass, uncovered fruit cups were transported on meal trays through hallways, and the Dietary Manager acknowledged that lids existed but were not used. Review of dishwasher logs showed repeated failures to meet required minimum final rinse temperatures, and requested kitchen cleaning logs were not provided.
Surveyors observed a brown substance on the floor in one lounge area and a persistent brown streak on a fitted sheet near the pillow in a resident’s bed over multiple days. The DON reported that a family member’s dog sometimes has accidents in the building and that she expects the lounge to be clean, but no documentation of the dog’s visits or a cleaning schedule for the lounge was provided. Record review showed the affected resident received multiple bed baths during the period when the soiled sheet remained in place, and the DON stated that linens are expected to be changed on bath days and whenever they become soiled.
Surveyors found that medications and biologicals were not properly labeled on two medication carts and in one medication room. An LPN showed an opened Novolog insulin FlexPen with missing units but no resident name or open date, and the LPN could not identify the resident, opening date, or expiration. Another LPN had an open stock bottle of liquid protein on a cart with no open date, and an opened vial of Aplisol tuberculin testing solution in a medication room also lacked an open date. These findings conflicted with facility policy and professional standards requiring complete labeling and dating of opened multi-dose products.
The facility failed to follow its own policy requiring hot foods to be held at or above 135°F and cold foods at or below 41°F, and to serve all items at palatable temperatures. A resident reported that his food was always cold, and a test tray showed both hot and cold items outside required temperature ranges, with the Dietary Manager confirming the items were out of range. Review of multiple months of food temperature logs showed repeated instances of cold items such as fruit, salads, sandwiches, puddings, and other cold dishes being served between approximately 46°F and just over 50°F, demonstrating a pattern of not maintaining proper cold-holding temperatures. The NHA and DON stated they would expect food to be served at appropriate temperatures.
The facility failed to follow its infection prevention and control policies by not implementing enhanced barrier precautions for two residents with indwelling urinary devices and open wounds, including an unstageable pressure ulcer with drainage, as evidenced by the absence of required signage, physician orders, and care plan interventions. Surveyors also observed exposed medication spoons stored on two medication carts and an LPN who did not perform hand hygiene between residents, touched multiple surfaces with contaminated gloves, administered oral medications and eye care without changing gloves, and carried a used washcloth down the hall before handwashing, contrary to expected infection control practices.
A resident with major depressive disorder and dementia was started on Depakote 250 mg at bedtime for mood without documentation that the risks and benefits of this psychotropic medication were explained and consent obtained, as required by facility policy. The resident’s care plan reflected use of antidepressant and mood stabilizer medication related to depression, but the DON confirmed there was no appropriate diagnosis documented in the medical record to support Depakote use. This failure to follow the psychotropic medication policy resulted in a deficiency under nursing services.
The facility failed to ensure accurate MDS assessments for three residents, resulting in incorrect coding of mental status and psychotropic medication use. One resident with depression and dementia was inaccurately coded as receiving antipsychotic drugs despite no documentation of such use in the 7‑day look‑back period. Another resident with depression and anxiety was coded as comatose on the admission MDS, while the nursing assessment documented that she was alert and oriented. A third resident with dementia and anxiety, who had active orders and documented administration of Buspirone and Xanax, was coded on the quarterly MDS as not receiving antianxiety medications during the look‑back period.
A resident admitted after surgical repair of a hip fracture, with diagnoses including a left femoral neck fracture and post–joint replacement aftercare, had physician orders for twice-daily enoxaparin. Facility policy required baseline care plans to include initial goals and physician orders necessary for effective, person-centered care. However, review of the resident’s baseline care plan showed no care area addressing anticoagulant use or monitoring for side effects. In an interview, the NHA and DON confirmed that the care plan did not include anticoagulation management, despite the facility’s expectation that care plans be accurate.
A resident with dementia and bilateral heel pressure ulcers remained care planned for wound infection and Contact Precautions even after physician orders discontinued Contact Precautions. Facility policy required ongoing assessment and care plan revision with condition changes and at least quarterly with MDS assessments. Although a Significant Change Comprehensive MDS and a Quarterly MDS were completed, the care plan was not updated to remove Contact Precautions until months later, which the DON acknowledged should have occurred when the orders changed or at the time of the MDS assessments.
Staff failed to follow professional standards when a resident with cognitive communication deficit and metabolic encephalopathy did not have a prescribed wanderguard bracelet in place on multiple occasions, even though documentation indicated it was applied and checked each shift. Additionally, a legally blind resident had Voltaren gel and wound treatment cream left within reach on a bedside stand, while the roommate with dementia and delusional disorder ambulated independently in the shared room. The DON later confirmed that these topical medications and cream should not have been left accessible.
A resident with dementia and bilateral heel pressure ulcers experienced severe unplanned weight loss of over 11% in one month, as documented by weights decreasing from 131 to 116.2 pounds. Facility policy required prompt reweighing and immediate written notification to the dietitian for weight changes of 5% or more, but there was no documentation that the resident was reweighed or that the dietitian or physician were notified during the week following the low weight. The DON later confirmed that neither nursing staff nor the dietitian addressed the weight loss until it was brought to their attention by surveyors, at which time the resident’s weight had decreased further.
A resident with diabetes and hemiplegia, receiving enteral nutrition, did not receive tube feeding care in accordance with facility policy and physician orders. On multiple observations, the feeding pump was found idle and inactive, and the Glucerna formula bottle and tubing at the bedside were not labeled with the date or time they were opened and hung, despite policy requiring this documentation. MAR review showed ordered Glucerna 1.5 bolus feeds every four hours, but the resident received 0 ml at two scheduled administration times. The DON reported there was an equipment issue and that the correct pumps were not available to administer the ordered tube feeding and acknowledged that feeds should have been labeled and dated per policy.
Surveyors found that two residents did not receive respiratory care consistent with professional standards and physician orders. One resident with COPD and malnutrition was observed twice receiving supplemental O2 via nasal cannula at 2 L/min without any corresponding physician order, despite facility policy requiring an order for oxygen therapy. Another resident with morbid obesity and obstructive sleep apnea had a physician order and care plan directing that the CPAP mask be stored in a bag when not in use, yet repeated observations and reports from the resident’s guardian showed the CPAP mask left unbagged on the nightstand, and the DON acknowledged that physician orders were not followed.
A resident with documented PTSD and major depressive disorder, who reported a history of childhood sexual abuse, did not receive trauma-informed, culturally competent care as required by facility policy. The psychosocial evaluation incorrectly indicated the resident did not have PTSD, and the comprehensive care plan lacked any focus or interventions related to PTSD or trauma. No additional trauma screening or documentation of trauma-informed care was found in the clinical record, despite leadership stating that residents are expected to receive trauma-informed care.
A resident with bipolar II disorder and major depressive disorder was prescribed olanzapine (Zyprexa) for behaviors/mood and pantoprazole (Protonix) once daily. Pharmacy medication regimen reviews identified that Protonix should be given on an empty stomach before a meal and that an appropriate diagnosis should be documented for Zyprexa. Although the physician signed both recommendations, the Protonix administration time remained scheduled after breakfast, and the Zyprexa order was not updated to reflect the bipolar II diagnosis. During interviews, the NHA and DON could not explain why the pharmacist’s recommendations were not implemented, despite facility policy requiring that such recommendations be acted upon and documented.
Surveyors identified that the facility failed to keep its medication error rate below 5%, with two errors out of 29 observed doses. In one case, an LPN administered sucralfate to a resident after the resident had already eaten, contrary to the order to give it before meals and at bedtime. In another case, an LPN administered antibiotic eye drops followed immediately by lubricating eye drops to a resident without waiting the required interval between ophthalmic medications as specified in facility policy. The NHA and DON acknowledged that medications are expected to be administered as ordered and per standard practice guidelines.
A resident with COPD and protein-calorie malnutrition was documented on the MDS as receiving hospice services, but review of the clinical record showed there was no corresponding physician order for hospice care. The facility’s hospice program policy did not specify that a physician order was required for hospice services, and the NHA and DON confirmed that no such order existed, despite their stated expectation that physician orders be in place for all care and services.
Two residents dependent on staff for ADLs did not receive required assistance with eating and timely continence care. One resident with dementia, hypertension, and major depressive disorder had care plan and physician orders for full feeding assistance with cueing and encouragement, yet staff left a meal tray at the bedside while the resident slept, did not return to cue or assist, and documented a refusal to eat before the tray was delivered. Another resident with hypertension, major depressive disorder, a self-care performance deficit, and need for one-person assist with a rollator repeatedly used the call light for continence care; staff turned off the call light, delayed care to finish passing meal trays, and only provided care after a wait, despite the resident reporting burning skin and being unable to toilet independently. The DON stated she expected staff to provide eating assistance and timely continence care.
The facility failed to administer and document medications according to physician orders and internal policy for three residents, including one with epilepsy and dementia whose ordered anticonvulsant (lacosamide) ran out and was not available for multiple scheduled doses. Nursing staff erroneously documented a dose as given when no tablets remained, marked subsequent doses as held due to pharmacy issues, and did not notify the physician about the missed doses until after the resident experienced seizure activity requiring two hospital transfers, during which no acute seizure medications were available at the facility. Two other residents with dementia and anxiety or respiratory conditions had blank MAR entries, conflicting documentation between the MAR and controlled substance records for Xanax, missing receipt verification for controlled substances, and undocumented reasons for missed or held doses of buspirone, Tylenol, Xanax, albuterol, geri-tussin, and Protonix.
The facility failed to ensure timely acquisition, dispensing, and administration of controlled medications for two residents, resulting in missed doses and harm to a resident with epilepsy. One resident with epilepsy and dementia did not receive ordered lacosamide for several scheduled doses after staff documented the drug as on order, on back order, and not available, despite prior reordering and multiple calls to the pharmacy. The resident subsequently experienced two seizures and was transferred to the hospital twice while lacosamide remained unavailable and access to the emergency supply was blocked due to pharmacy requirements for a current script. Another resident with dementia and anxiety did not receive scheduled Xanax while staff awaited pharmacy delivery, and the RN had to obtain a one-time order using an alternate tablet strength after the pharmacy declined to allow dose substitution from the emergency supply. The controlled substance record for this resident’s Xanax showed the prescription had been filled earlier, but receipt verification was not completed and the first dose from the package was delayed.
A resident with dementia and hypertension experienced an unwitnessed fall in a lounge area after dinner. Staff statements did not confirm the resident's location at the time of the fall, and the care plan intervention to assist the resident to her room after dinner was not followed. The lack of supervision and failure to implement the care plan led to the incident.
A resident with dementia and heart failure did not receive ordered foam handled utensils or have their food cut up during a meal, despite physician orders and care plan interventions. Observation showed another resident had to assist by cutting up the food, and the lunch tray ticket indicated the need for adaptive utensils, which were not provided. The NHA confirmed these omissions.
A resident with dementia and a history of exit-seeking behaviors eloped from the facility after staff failed to implement effective interventions and supervision, including the absence of electronic monitoring devices and inadequate monitoring of exit doors. The resident was missing for over 17 hours and sustained injuries before being found, while additional residents at risk for elopement were also left without adequate protections.
The facility failed to properly monitor and maintain the nutritional status of three residents, leading to significant weight loss and inadequate physician notification. One resident experienced a 28-pound weight loss due to missed weight checks and lack of physician notification. Another resident's daily weights were inconsistently documented, and significant weight gains were not reported to the physician. A third resident experienced significant weight loss attributed to diuretic therapy, with no evidence of physician involvement in addressing the issue.
The facility failed to provide adequate transfer notices for residents hospitalized due to medical conditions. Notices lacked required mailing addresses, and some transfers were undocumented. Staff confirmed these deficiencies during interviews.
The facility failed to provide complete bed-hold notices to residents upon transfer or discharge. Several residents, including those with heart failure, dementia, and diabetes, did not receive notices with required information about the state bed-hold duration and reserve payment. Staff interviews confirmed these omissions, indicating a systemic issue in the facility's process.
The facility failed to ensure resident participation in care planning and did not adequately document or update care plans for several residents. A resident was not invited to care plan meetings, while others had missing documentation for skin rashes and medication use. The DON confirmed these omissions were against facility expectations.
The facility failed to monitor side effects and target behaviors for two residents on psychotropic medications. One resident was prescribed Abilify for hallucinations, but monitoring was incorrectly documented, and no behavior monitoring was in place. Another resident, after hospitalization, lacked documentation for antipsychotic use and target behaviors. The DON and NHA confirmed these oversights, acknowledging the need for proper monitoring.
The facility failed to maintain professional standards for food service safety by not recording dish machine temperatures during dinner for several months. Interviews revealed that the absence of management during dinner might have contributed to this oversight.
The facility failed to ensure accurate resident assessments for three residents. One resident's significant weight loss was not correctly documented in the MDS, another had conflicting weight change records, and a third resident's urinary catheter was not recorded. These discrepancies were confirmed by staff and required correction.
A facility failed to adhere to its Enhanced Barrier Precautions policy during the care of a resident with a pressure ulcer. The resident, diagnosed with dementia and hypertension, had an unstageable pressure injury and was on droplet precautions for influenza. An LPN did not wear a gown during wound treatment, despite the requirement for gowns, gloves, and masks under the facility's policy. The DON confirmed the need for both droplet and Enhanced Barrier Precautions.
The facility failed to prevent accidents for two residents. One resident with Alzheimer's was left alone in the bathroom despite needing assistance, leading to an unwitnessed fall. Another resident with dementia had a fall mat improperly placed, contrary to their care plan, resulting in a fall. These deficiencies highlight lapses in supervision and adherence to care plans.
A facility failed to assist a resident with obtaining necessary dental care, including the extraction of upper teeth for a full-upper denture. Despite a dental consultation recommending x-rays and an oral surgery consult, these were not followed up. The facility's process involved a 'Visit Summary' document, which did not include these recommendations, resulting in no further treatment. The resident, with hypertension and diabetes, reported issues with a partial denture.
The facility failed to implement proper infection control measures, including PPE use and handling of contaminated items. An LPN did not follow contact precautions for a resident with influenza, returning unused gauze to the treatment cart. Another employee ignored droplet precautions for a resident with influenza A, and a third employee did not use PPE or hand hygiene for a resident with scabies. The Nursing Home Administrator confirmed these lapses.
The facility failed to document that education on the influenza vaccine's risks, benefits, and side effects was provided to two residents or their representatives. One resident's representative refused the vaccine without documented education, while another resident received the vaccine without evidence of education. The facility's Infection Preventionist and NHA confirmed the lack of required documentation.
The facility failed to document that two residents or their representatives were educated on the risks, benefits, or side effects of the COVID-19 vaccine. Despite the facility's policy requiring such documentation, it was absent for these residents. Interviews revealed that verbal education was provided, but no consent or declination forms were used.
The facility failed to ensure the presence of required multidisciplinary members at Infection Control Committee meetings, as mandated by the Mcare Act. Laboratory personnel, physical plant personnel, and a community member were absent from meetings in 2024. The Nursing Home Administrator confirmed the absence and noted corporate instructions regarding physical plant personnel attendance.
The facility failed to implement effective infection control practices to prevent the spread of scabies among residents. Despite an increase in skin rashes and a confirmed case of scabies, the facility did not conduct skin scrapings for other residents with rashes and lacked a specific policy for scabies management. Only two residents were on contact precautions, and the facility did not secure testing for others, contributing to the deficiency.
A resident with dementia and hypertensive heart disease was physically abused by a staff member during an attempt to clean the resident. The resident became combative and hit the staff member, who retaliated by hitting the resident twice. The incident was reported, and the resident was taken to the hospital and returned with no identified concerns. Observations showed light bruising to the resident's right eye.
A resident with dementia and hypertension had a rash on their arm, reported by family. A physician ordered hydrocortisone cream, but no assessment of the rash's characteristics was documented. The DON confirmed the lack of assessment, and the NHA stated it was expected to be done.
A resident under hospice care experienced critically low oxygen saturation levels, but the facility failed to notify hospice in a timely manner as required by policy. Despite the resident receiving morphine for comfort, hospice was only contacted the next morning after a representative's request, highlighting a lapse in communication during a significant change in the resident's condition.
The facility failed to ensure proper monitoring and timely implementation of nutritional interventions for four residents, resulting in significant weight changes and harm. The facility lacked dietitian coverage, and nursing staff did not notify physicians or consult the corporate Certified Dietary Manager promptly.
The facility failed to develop and implement a Water Management Program for preventing, detecting, and controlling water-borne contaminants like Legionella. Despite having a policy and a designated water management team, the facility could not provide an assessment or evidence of preventive measures. The Nursing Home Administrator confirmed the lack of implementation.
The facility failed to accommodate a resident's needs and preferences as outlined in her care plan. The resident, who has dementia, legal blindness, and generalized anxiety disorder, had her cell phone placed out of reach and her meal tray inconsistently arranged, contrary to her care plan instructions.
The facility failed to ensure accurate resident assessments for six residents, including errors in documenting hospice services, medication administration, physical restraints, falls, and CPAP usage. These inaccuracies were confirmed through clinical record reviews and staff interviews.
The facility failed to update the comprehensive care plans for three residents upon changes in their conditions. One resident's care plan for a resolved pressure ulcer remained active, another resident's fall prevention plan did not account for their tendency to remove socks, and a third resident's care plan for oxygen therapy was not updated after the therapy was discontinued.
The facility failed to follow care protocols and provided inconsistent wound documentation for four residents. An LPN did not adhere to hand hygiene protocols during a dressing change, a resident with a forearm fracture did not consistently wear a required splint, another resident's wound was inconsistently documented and classified, and a resident with a UTI did not have vital signs monitored as care planned.
The facility failed to consult qualified dietary staff to assess the nutritional needs of residents in the absence of a qualified dietitian for four residents. Clinical record reviews revealed significant gaps in nutritional assessments for residents with conditions such as dementia, dysphagia, anemia, and vitamin D deficiency. The facility did not consult the corporate Certified Dietary Manager during the period without a Dietitian.
The facility failed to store food and monitor equipment according to professional standards, with multiple instances of undated and expired food items, improper sanitizing solution concentration, and incomplete temperature logs in the main kitchen and pantry areas.
Missed Warfarin Doses and PT/INR Monitoring Due to Order Entry Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from significant medication errors related to warfarin therapy and required PT/INR monitoring. The resident had diagnoses including chronic embolism and thrombosis of unspecified deep veins of the left lower extremity and dementia. A physician order entered by an employee on February 24, 2026, directed that the resident receive warfarin 2.5 mg at bedtime starting February 25, 2026, with a PT/INR recheck scheduled for March 11, 2026. The Medication Administration Record showed that the resident received warfarin from February 25 through March 10, 2026, but did not receive any warfarin from March 11 through March 17, 2026. The clinical record contained no evidence that the ordered PT/INR was completed on March 11, 2026. A progress note on March 18, 2026, documented that a registered nurse discussed concerns about the resident’s PT/INR and missed warfarin doses with night shift staff and informed the resident’s physician, who was present in the facility. A physician progress note later that day indicated that staff had noted the resident missed a few days of warfarin and that an order for a stat PT/INR was given, with the resident restarted on her previous warfarin dose and a new order to recheck PT/INR in a week. The resident’s March 2026 Medication Administration Record showed that warfarin administration resumed on March 18, 2026, and the Treatment Administration Record showed a scheduled PT/INR lab draw for March 24, 2026. During an interview, the Regional Director of Clinical Services confirmed that the employee who entered the original orders had signed off on the lab order in a way that prevented it from populating on the resident’s record and had also set the medication order to stop on the date the lab was ordered, resulting in the resident not receiving the ordered lab test or warfarin doses during the identified period.
Widespread Food Safety, Sanitation, and Hand Hygiene Failures in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own policies for food safety and sanitation. Facility policies required proper food storage, labeling, dating, covering of foods, use of utensils to avoid bare-hand contact, routine cleaning and sanitizing of equipment, and appropriate employee sanitary practices, including hair coverings. Surveyors observed multiple violations of these policies in the main kitchen, nourishment refrigerators on two units, and during tray line and tray pass observations. The Nursing Home Administrator (NHA) acknowledged that foods should be labeled, dated, and stored properly, that cleaning should be completed routinely, and that sanitary policies should be followed. In the kitchen, surveyors observed widespread cleanliness and storage issues. The ice machine had pink residue on a plastic guide and heavy dust on its water filter and hose. The shelving unit and drawers under the coffee maker were soiled with coffee grounds and spills, with dried coffee in contact with clean cup lids and juice caps stored with those lids. Food debris, including what appeared to be a piece of hot dog, was found on the floor between the ice machine and coffee stand. The beverage reach-in refrigerator contained multiple opened beverages (prune juice, thickened juices, milk) without open dates, an unlabeled red beverage that had spilled inside the unit, and a soiled base and surrounding floor. Additional issues included dusty and debris-contaminated lid storage bins, blender bases with food debris, a thickener bin with the scoop stored inside and a soiled lid, yellow powdery residue in a utensil drawer, heavily soiled stove and floors, food debris under and around equipment, soiled pot holders, and a mixer and dish room walls with food debris. The can opener had heavy black buildup despite policy requiring daily washing and sanitizing, and some spices were past the facility’s stated discard timeframe. Dish racks and dishes were stored upright and uncovered with visible debris, and utensils were found with dried residue and lying on a soiled counter used as a drying area. Test strips for the three-compartment sink included an expired bottle. Food storage and labeling deficiencies were also documented in the walk-in refrigerator, freezer, dairy cooler, dry storage, and nourishment refrigerators. In the walk-in units, surveyors found multiple opened items without dates (milk, thickened milk, juices, frozen blueberries), unlabeled or undated prepared foods (chicken and rice soup, meat patties, cheese slices), items past their discard dates (ham, pork), unsecured or partially unwrapped products, and an unlabeled bag of frozen food that staff identified only after questioning. Dry storage logs were incomplete, with no temperature entries after a certain date, and there was no thermometer or temperature log in a second dry storage area containing cereal and creamers. Opened bakery items and other dry goods (rolls, pecans, Craisins, pancake mix, sprinkles) lacked open dates or were unsecured. On the units, nourishment refrigerators contained opened thickened beverages and supplements without open dates, multiple unopened beverages and frozen items without resident names, and a cloth-covered ice pack labeled with a resident’s name stored on the same shelf as food. One nourishment refrigerator lacked a temperature log, and its freezer had no thermometer. Surveyors also identified failures in employee sanitary practices and dishwashing temperature monitoring. In the kitchen, the Dietary Manager handled expired hand sanitizer bottles while wearing gloves, discarded them, and then immediately returned to food preparation and continued making a quesadilla with the same gloves until stopped by the surveyor; he then acknowledged the issue and washed his hands only after being prompted. During tray line observation in the main dining room, a dietary aide wore a baseball cap with exposed hair and repeatedly used a gloved hand to touch and guide salmon patties, green beans, and noodles onto plates while also handling paper meal tickets. The aide then placed both gloved hands on the lid of a soiled linen hamper and returned to serving food without changing gloves or washing hands, which he confirmed he had been about to continue doing. During tray pass on one unit, approximately 20 meal trays were observed with small cups of pears that were uncovered while being transported through hallways, and the Dietary Manager stated that lids were available but not used. Review of the dishwasher temperature logs showed repeated failures to meet the required minimum final rinse temperature of 180°F and, on at least one occasion, a wash temperature below the required 140°F. Across multiple dates in November, December, and January, final rinse temperatures were documented in the 150s and 160s, below the facility’s stated minimum. One day’s wash and rinse temperatures were scribbled out, and no additional information was provided regarding these temperature deficiencies. Kitchen cleaning logs requested by surveyors were not provided. In interviews, the NHA and Director of Nursing confirmed that staff should not have returned to food preparation with contaminated gloves or touched food directly, and the NHA acknowledged that dietary staff had been refilling and continuing to use expired hand sanitizer bottles and that the kitchen could have followed sanitary guidelines better.
Failure to Maintain Clean, Homelike Environment in Lounge and Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, comfortable, and homelike environment in a common lounge and in a resident’s room. During observation of the Faith East lounge, surveyors noted a brown substance on the floor in the corner of the room. In an interview, the DON stated she would expect the room to be clean and reported that a resident’s family member sometimes brings a dog into the building that has accidents. When surveyors requested documentation of the dog’s last visit and a cleaning schedule for the Faith East lounge, no additional information was provided. In a separate observation, a brown streak was seen on the fitted sheet of a resident’s bed, located on the right side at the head of the bed near the pillow. This same brown streak was observed on multiple subsequent days, despite clinical record review showing that the resident received bed baths on several evenings during that period. The DON stated that sheets are usually changed on shower or bath days and that sheets should be changed if they become soiled between those days. The DON acknowledged that she would have expected staff to change the resident’s sheet when it became soiled during the times the resident received bed baths.
Improper Labeling of Insulin, Liquid Protein, and Tuberculin Solution
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were properly labeled in accordance with facility policy and accepted professional standards. The facility’s Medication Labeling and Storage policy, dated February 2023, required that medication labels include, at a minimum, the medication name, prescribed dose, strength, expiration date when applicable, resident’s name, route of administration, and appropriate instructions and precautions. The policy also required that multi-dose vials opened or accessed be dated and discarded within 28 days unless otherwise specified by the manufacturer. Reference materials indicated that Novolog (insulin aspart) should be used or discarded within 28 days of opening, Medline Liquid Active Protein should be used or discarded within three months of opening, and tuberculin skin testing solution (Aplisol) expires 30 days after initial puncture. During observation of the Faith Short medication cart with an LPN, surveyors found an opened Novolog insulin FlexPen with approximately 200 units remaining, no resident name on the pen, and no date indicating when it was opened; the LPN confirmed that about 100 units were missing and that she did not know which resident it belonged to, when it was opened, or when it would expire. On the Love 1 medication cart, an LPN and surveyors observed an open stock bottle of liquid protein without an open date, and the LPN confirmed he would not know when it would expire. In the Faith Wing medication room, surveyors and an LPN observed an opened vial of Aplisol tuberculin testing solution with no open date on the vial, and the LPN confirmed she would not know when it would expire. In an interview, the DON confirmed the expectation that medications be labeled properly. These observations demonstrated noncompliance with the facility’s own policy and applicable state regulations regarding medication labeling and storage.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and maintained at safe and appetizing temperatures, as required by its policy. The policy titled "Serving of Food (Point of Service)" dated July 2025 required all hot food to be held at or above 135°F, cold food at or below 41°F, and all food items to be served at a palatable temperature. A resident interview revealed that one resident reported his food was always cold. A test tray taken for a specific resident on the Faith Wing cart showed that both hot and cold items were out of the required temperature ranges, with pears at 53.4°F, a salmon patty at 125.9°F, green beans at 117.5°F, and pasta at 112.8°F, and the Dietary Manager confirmed that all these temperatures were out of range and that the hot items were cold. Review of facility food temperature logs over multiple months showed repeated failures to maintain cold foods at or below 41°F. In November, December, January, and February, numerous cold items such as fruit cups, three bean salad, peaches, turkey and egg salad sandwiches, tossed salads, puddings, fresh fruit, cucumbers, cole slaw, macaroni salad, tomato slices, vegetable salads, squash rounds, marinated vegetables, apple crisp, tuna salad, cottage cheese, beet salad, and mandarin oranges consistently measured between approximately 46°F and just over 50°F, above the facility’s stated cold-holding standard. These findings demonstrated an ongoing pattern of serving cold foods at temperatures higher than the policy requirement. During an interview, the Nursing Home Administrator and the DON acknowledged that they would expect food to be served at appropriate temperatures.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies, including enhanced barrier precautions (EBP), for residents with qualifying conditions and to maintain appropriate infection control during medication administration. Facility policy on EBP, revised December 2024, states that EBP apply when a resident is not known to be infected or colonized with an MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that cannot be contained. Resident 11 had diagnoses including an artificial opening of the urinary tract and an open abdominal wall wound, with a nephrostomy and a urostomy in place, but there was no EBP signage on the room door, no physician order for EBP, and no care plan addressing EBP. Resident 35 had an unstageable pressure ulcer and venous ulcers, including an unstageable pressure ulcer on the right plantar foot with moderate serosanguinous drainage, yet there was no EBP signage on the room door, no physician order for EBP, and no care plan addressing EBP. In interviews, the DON stated that both residents should have been on EBP and that facility policy should have been followed. Additional infection control deficiencies were identified during medication administration observations. On two separate medication carts, spoons used for medication administration were stored completely exposed—on one cart in a plastic bin on top of the cart and on another in a box on the side of the cart. During a medication pass, an LPN (Employee 4) did not perform hand hygiene between administering medications to two residents. The LPN donned gloves before entering a resident’s room to administer eye drops and clean the resident’s eyes, then touched the trash can lid and medication cart handles with the gloved hands, adjusted the resident’s bed using the bed control panel, and administered oral medications without changing gloves. The LPN then opened the resident’s bathroom door, wetted a washcloth, cleansed and dried the resident’s eyes, and administered eye drops while still wearing the same gloves, exited the room carrying the used washcloth, removed gloves at the cart, and carried the washcloth down the hall to the soiled utility room before performing hand hygiene. The DON confirmed the expectation that nursing staff follow appropriate infection control guidelines during medication administration.
Lack of Informed Consent and Appropriate Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to provide an explanation of the risks and benefits of psychotropic medication use and obtain consent prior to administering a psychotropic medication to one resident. Facility policy on psychotropic medication use, revised February 2025, stated that residents who had not used psychotropic medications were not to be prescribed or given these medications unless necessary to treat a specific, diagnosed, and documented condition. Resident 9’s clinical record showed diagnoses of major depressive disorder and dementia, and a physician’s order for Depakote 250 mg by mouth at bedtime for mood beginning on September 12, 2025. The resident’s care plan included a focus that the resident used antidepressant and mood stabilizer medication related to depression, last revised on September 21, 2025. However, during an interview on February 11, 2026, at 11:45 AM, the Director of Nursing stated that Resident 9 did not have an appropriate diagnosis for Depakote documented in the medical record, indicating the medication was used without the required documented diagnosis and without documented explanation of risks and benefits and consent. This deficiency was cited under 211.12(d)(1)(3)(5) Nursing services.
Inaccurate MDS Coding for Mental Status and Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected three residents’ clinical status and medication use. For one resident with major depressive disorder and dementia, the annual MDS coded antipsychotic medication use in Section N0415 during the 7‑day look‑back period, but review of the clinical record showed no evidence that any antipsychotic medications had been administered during that time. For a second resident with major depressive disorder and anxiety disorder, the admission comprehensive MDS coded the resident as comatose and in a persistent vegetative state with no discernible consciousness in Section B0100, while the admission nursing assessment documented that the resident was alert and oriented to person, place, and time. For a third resident with dementia and anxiety disorder, physician orders and the medication administration record showed scheduled administration of Buspirone every eight hours and Xanax every 12 hours for anxiety/behaviors during the MDS look‑back period. However, the quarterly MDS coded that resident as not receiving antianxiety medications in the 7‑day look‑back period. Staff interviews with the MDS Coordinator and facility leadership confirmed that these MDS assessments had been coded incorrectly, and the Nursing Home Administrator and DON stated that their expectation was that MDS reports be coded accurately.
Failure to Include Anticoagulation Management in Baseline Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for a resident. Facility policy titled “Care Plans - Baseline,” revised April 24, 2025, required that baseline care plans include instructions needed to provide effective, person-centered care and specified that they must contain initial goals based on admission orders and physician orders. For one resident, the baseline care plan did not include a care area addressing the use of anticoagulation medication or monitoring for side effects, despite existing physician orders and the resident’s clinical condition. Clinical record review showed that the resident had diagnoses including a fracture of the neck of the left femur and aftercare following joint replacement surgery, and had been admitted from the hospital after surgical repair of a hip fracture. Physician orders for this resident included enoxaparin sodium administered twice daily. Review of the resident’s baseline care plan did not reveal any care area related to anticoagulant use or monitoring for side effects. In an interview, the Nursing Home Administrator and DON confirmed that the resident’s care plan lacked a care area for anticoagulation medication use and side effect monitoring and acknowledged that it was the facility’s expectation that resident care plans be accurate.
Failure to Timely Revise Care Plan After Discontinuation of Contact Precautions
Penalty
Summary
The facility failed to ensure that a resident’s comprehensive person-centered care plan was reviewed and revised in a timely manner when the resident’s condition and orders changed. Facility policy required that resident assessments be ongoing and that care plans be revised as resident information and conditions change, as well as reviewed and updated at least quarterly in conjunction with required quarterly MDS assessments. The resident had diagnoses including dementia and pressure ulcers to both heels and had been placed on Contact Precautions, which were reflected in a care plan focus for wound infection and Contact Precautions dated October 28, 2025. Physician orders for this resident discontinued Contact Precautions on November 1, 2025, and the clinical record showed a Significant Change Comprehensive MDS completed on November 17, 2025, and a Quarterly MDS completed on December 3, 2025. Despite these changes and required assessments, the care plan continued to list Contact Precautions and was not revised to reflect the discontinued orders until February 9, 2026. During an interview, the DON confirmed that Contact Precautions had been discontinued on November 1, 2025, and acknowledged that the care plan was not revised until February 9, 2026, although she would have expected it to be updated when the orders changed or at least at the time of the MDS assessments.
Failure to Follow Physician Orders and Secure Topical Medications
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards for three residents. One resident with cognitive communication deficit and metabolic encephalopathy had a physician’s order for a wanderguard bracelet to be placed on the left lower extremity, with staff to check its function and placement every shift. On multiple observations over several days, the resident’s wanderguard bracelet was seen lying on the overbed table while the resident ambulated in the room, often barefoot, and the resident stated he only had to wear the bracelet for seven days. Despite these observations, the February Treatment Administration Record documented that the wanderguard bracelet was in place every shift and that its function was checked nightly. Another resident, who required assistance with personal care and was legally blind, was observed on multiple occasions with a tube of Voltaren gel and a tube of wound treatment cream lying on the bedside stand within reach. During a medication pass with an LPN, these items remained accessible on the bedside stand. The roommate of this resident had diagnoses of dementia and delusional disorder and was care planned and observed to ambulate independently around the room. During a follow-up observation and interview with the Nursing Home Administrator and DON, the DON confirmed that the medication and cream should not have been left on the bedside stand.
Failure to Timely Address Severe Unplanned Weight Loss
Penalty
Summary
The facility failed to address significant weight loss in a timely manner for one resident. Facility policy on Weight Assessment and Intervention required that any weight change of 5% or more since the last assessment be rechecked the next day, and if verified, that nursing immediately notify the dietitian in writing. The policy also defined a 5% weight loss in one month as significant and greater than 5% as severe. The resident had diagnoses including dementia and bilateral heel pressure ulcers. A nutritional assessment by the facility dietitian in early December 2025 indicated the resident was not at risk for unintended weight loss. Weight records showed that the resident weighed 131 pounds on January 7, 2025, and 116.2 pounds on February 4, 2025, an 11.3% (14.8-pound) loss in 30 days, which met the facility’s criteria for severe unplanned weight loss. Review of the clinical record on February 11, 2026, revealed no documentation between February 4 and February 11 that the resident had been reweighed or that the dietitian or physician had been notified of the weight loss, as required by policy. During an interview, the DON stated that the resident was only reweighed on the morning of February 11 after the surveyor questioned the weight loss and confirmed that neither nursing staff nor the dietitian had addressed the weight loss before that time. The DON also confirmed that the resident’s weight on February 11 was 115.6 pounds, reflecting an additional 0.6-pound loss.
Failure to Follow Enteral Feeding Orders and Labeling Policy for Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services for a resident receiving tube feedings in accordance with facility policy and physician orders. Facility policy for enteral tube feeding via continuous pump required staff to document initials, date, and time on the formula label when the formula was hung and to verify the label against the order. The resident had diagnoses including diabetes and hemiplegia. On two separate observations, the resident’s feeding pump was found idle and inactive for at least 10 minutes, and the bottle of Glucerna and tubing at the bedside were not labeled with the date or time they were opened and hung, contrary to the facility’s policy. Review of the resident’s February MAR showed an order for Glucerna 1.5 as gravity/bolus enteral feedings every four hours, with specified volumes at each administration time. The MAR further showed that the resident received 0 ml of Glucerna 1.5 at two scheduled administration times. During interviews, the DON stated there was an equipment issue and that the facility did not have the correct pumps to administer the ordered Glucerna 1.5, and also acknowledged that she would expect the resident’s tube feed to be labeled and dated per facility policy. These findings demonstrate that the facility did not follow its own enteral feeding policy and did not ensure ordered tube feedings were administered as prescribed for this resident.
Failure to Follow Physician Orders for Oxygen Therapy and CPAP Care
Penalty
Summary
The facility failed to ensure respiratory care and services were consistent with professional standards for two residents receiving respiratory-related treatments. For one resident with COPD and protein-calorie malnutrition, surveyors twice observed the resident receiving supplemental oxygen via nasal cannula at 2 liters per minute. Review of the resident’s clinical record and physician orders showed there was no physician order for supplemental oxygen, despite facility policy requiring a physician’s order for oxygen therapy and verification of such an order before the procedure. In an interview, the DON confirmed that the resident did not have a physician order for supplemental oxygen, and both the NHA and DON stated it was the facility’s expectation that physician orders be obtained and entered for supplemental oxygen use. For another resident with morbid obesity, obstructive sleep apnea, hypertension, and anxiety, the comprehensive care plan documented that the resident uses a CPAP, and a physician’s order directed that the CPAP mask be placed in a storage bag when not in use on every day and evening shift. The resident’s guardian reported that she visits almost daily and often finds the CPAP mask not clean and never bagged. On three separate observations of the resident’s room, surveyors found the CPAP and mask on the nightstand, not bagged, contrary to the physician’s order. In an interview, the DON stated she would expect physician orders to be followed and for the resident’s CPAP mask to have been bagged as ordered.
Failure to Provide Trauma-Informed, Culturally Competent Care for a Resident With PTSD
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care to a resident with known trauma history and PTSD. Facility policy on Trauma Informed Care and Culturally Competent Care, revised April 22, 2025, stated that assessment should involve an in-depth evaluation of symptoms, their relationship to trauma, and identification of triggers to minimize or prevent re-traumatization. Clinical record review for Resident 10 showed diagnoses including post-traumatic stress disorder (PTSD) and major depressive disorder. During an interview, the resident disclosed having suffered sexual abuse as a young child. However, the admission social service evaluation dated December 23, 2025, documented in the psychosocial evaluation section that the resident did not have a diagnosis of PTSD. Further review of the resident’s comprehensive care plan did not reveal any focus area or interventions addressing PTSD or trauma. The clinical record also lacked evidence that any additional trauma screening had been completed. The facility was unable to provide documentation indicating that the resident had received trauma-informed care in accordance with its policy and professional standards of practice. In an interview, the Nursing Home Administrator and DON stated that it was the facility’s expectation that residents receive trauma-informed care, but no supporting documentation was available for this resident.
Failure to Implement Pharmacist Medication Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to implement licensed pharmacist recommendations from monthly medication regimen reviews for one of five residents reviewed for unnecessary medications. Facility policy titled "Medication Regimen Review (Monthly Report)," revised April 22, 2025, states that recommendations are to be acted upon and documented by facility staff and/or the prescriber. Resident 7 had diagnoses including bipolar II disorder and major depressive disorder, with physician orders for olanzapine (Zyprexa) at bedtime for behaviors/mood and pantoprazole (Protonix) once daily. In the December 2025 monthly medication review, the pharmacist recommended that Protonix be administered on an empty stomach 30–60 minutes before a meal. The physician signed this recommendation on January 6, 2026, but the resident’s order continued to schedule Protonix at 9:00 AM, after the facility’s breakfast meal service, indicating the recommendation was not implemented. In the January 2026 monthly medication review, the pharmacist recommended adding an appropriate diagnosis for Zyprexa. The physician signed this recommendation on February 9, 2026, specifying bipolar II disorder as the diagnosis; however, the physician’s orders for Zyprexa were not updated to reflect that it was prescribed for bipolar II disorder. During an interview on February 11, 2026, the Nursing Home Administrator and DON reported they had no additional information as to why the pharmacy recommendations were not implemented and stated it was the facility’s expectation that pharmacy recommendations be implemented. These findings were cited under 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services.
Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as required, resulting in a calculated error rate of 6.9% (two errors out of 29 opportunities). Facility policy for eye drop administration required staff to wait at least five minutes before applying additional medication to the eye. During a medication pass observation, one LPN administered sucralfate 1000 mg to a resident after the resident had already completed breakfast, despite the medication packaging specifying that it was to be given before meals and at bedtime. The LPN acknowledged during an immediate interview that she was running behind and that the medication was not administered as ordered. In a separate observation, another LPN administered Cipro HC 0.3% ophthalmic solution, one drop to each eye, and then immediately administered Refresh lubricating eye drops, one drop to each eye, without waiting between the two medications as required by facility policy. During an immediate interview, this LPN confirmed that the eye drops were given consecutively without the required interval. During a subsequent interview, the Nursing Home Administrator and Director of Nursing confirmed that they expected nursing staff to administer medications as ordered and in accordance with standard practice guidelines. These observed deviations from ordered medication administration and facility policy resulted in the cited medication error rate above the 5% threshold.
Failure to Obtain Physician Order for Hospice Services
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain and document a physician order for hospice services for one resident receiving hospice care. The facility’s hospice program policy, last reviewed April 22, 2025, did not specify that a physician order must be obtained for hospice services. Clinical record review for Resident 8 showed diagnoses including chronic obstructive pulmonary disease and protein-calorie malnutrition, and a significant change MDS dated December 19, 2025, indicated the resident was receiving hospice services under Section O for special treatments, procedures, and programs. However, review of the resident’s physician orders did not reveal any order for hospice services. In an interview, the NHA and DON confirmed that the resident did not have a physician order for hospice services and stated that it was the facility’s expectation that physician orders be in place for care and services. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 211.12(d)(3)(5) Nursing services, and 28 Pa. Code 201.18(b)(1)(3) Management, based on the lack of a documented physician order for hospice services despite the resident being identified as receiving hospice care on the MDS and the absence of a policy requirement to obtain such an order.
Failure to Assist With Eating and Timely Continence Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically eating and continence care, for residents dependent on staff support. Facility policy required appropriate care and services for residents unable to carry out ADLs independently, including hygiene, mobility, elimination, and dining, in accordance with the care plan. One resident with hypertension, major depressive disorder, and a documented self-care performance deficit related to dementia had a care plan and physician’s order stating that she required feeding assistance with all meals, with staff to cue, encourage, and then assist if she was not eating. On the observed date, the resident was found asleep in bed when a staff member placed her lunch tray on the bedside table and left without providing cueing or assistance. Later observation showed the resident still asleep with the tray untouched and covered, and no staff were seen entering the room to encourage or assist with eating. Documentation for that meal indicated the resident refused to eat, recorded at a time prior to the tray being delivered. A prior nursing note documented that this resident required assistance and cueing for eating and was able to consume 95% of a meal when assisted. The DON stated she would have expected staff to encourage and assist the resident with eating. The deficiency also includes failure to provide timely continence care for another resident with hypertension and major depressive disorder. This resident’s call bell was observed on, and a staff member entered the room, told the resident to give them a minute, turned off the call light, and left. Later, the resident reported needing assistance with continence care because his skin was burning and stated he could not get to the restroom independently and required staff assistance. He was observed wearing a brief and activated his call light again. Another staff member entered, told him she needed to finish passing meal trays before returning to provide continence care, and left. Continence care was not provided until several minutes later. The resident’s care plan documented a self-care performance deficit related to a humerus fracture and that he required one-person assistance with transfer and ambulation using a rollator. The clinical record showed that wound care evaluated him the following day for a fungal rash with excoriation to the sacrum and bilateral buttocks, and the DON stated she expected staff to provide continence care in a timely manner.
Failure to Administer and Document Medications per Orders and Policy, Resulting in Harm
Penalty
Summary
The deficiency involves the facility’s failure to provide medications in accordance with physician orders, professional standards, and facility policy, resulting in missed doses, inaccurate documentation, and lack of timely physician notification. Facility policy required medications to be administered per written orders, documented immediately on the MAR, and for withheld or refused doses to be coded with explanatory notes, with physician notification if two consecutive doses of a vital medication were missed. Policy also required appropriate ordering, receipt, and use of controlled medications, including timely reordering and use of emergency supplies when appropriate. These standards were not followed for three residents. For one resident with epilepsy and dementia, the physician had ordered lacosamide 100 mg orally every 12 hours. The controlled substance record showed 30 tablets received on December 29 and used beginning January 1, with the last available dose given on January 15 at 8:00 PM. Despite this, the January MAR showed a dose documented as given on the morning of January 16 by an LPN, even though no medication remained; the nurse later stated she had erroneously charted that administration. Subsequent MAR entries for lacosamide on January 16 (PM) and January 17 (AM and PM) were marked as held with notes indicating the drug was on order, on back order, or not available, and progress notes documented repeated calls to the pharmacy. There was no documentation that the physician was notified that four scheduled doses on January 16 and 17 could not be given until after the resident experienced seizure activity late on January 17, which led to transfer to the emergency room. The resident returned without the facility having lacosamide available, experienced another seizure the following morning, and was again sent to the hospital; documentation reflected ongoing uncertainty about when the last doses had actually been administered and that no acute seizure medications were available at the facility at those times. For a second resident with dementia and anxiety disorder, with orders for buspirone every 8 hours, Tylenol Extra Strength three times daily, and Xanax 0.5 mg every 8 hours, the January MAR showed blank entries for the 2:00 PM doses of all three medications on two separate days. On those same days, the controlled substance record showed the 2:00 PM Xanax doses signed out as administered by nursing staff, but there was no corresponding MAR documentation or progress notes explaining whether the medications were given or held. On another date, the MAR showed a 2:00 PM Xanax dose held with a note that it was not needed, while the controlled substance record showed the same dose signed out as administered, creating conflicting documentation. Later in the month, two scheduled Xanax doses were held due to awaiting pharmacy delivery, and progress notes described difficulty obtaining the ordered dose from the emergency supply and the need for a one-time alternative dose order. The controlled substance record for Xanax showed the prescription filled by the pharmacy the day before, but the receipt verification section was left blank, and the first dose from that package was not documented as given until later that day. For a third resident with dementia, hypertension, and cough, physician orders included albuterol nebulizer solution every four hours, geri-tussin syrup every four hours, and Protonix 40 mg in the morning. The November MAR showed blank entries for the 4:00 AM doses of albuterol and geri-tussin and the 6:00 AM dose of Protonix on a specific date, with no corresponding progress notes documenting whether these medications were administered, refused, unavailable, or intentionally held. During interviews, the DON stated she expected staff to administer medications as ordered, reorder medications when down to a five-day supply, follow up with the pharmacy when medications were not delivered, notify physicians promptly when medications were unavailable, and complete all MAR and controlled substance documentation, including receipt verification. The survey findings showed that these expectations and facility policies were not met for the three residents, resulting in missed or undocumented doses, conflicting records, and lack of timely physician notification when ordered medications were not available.
Failure to Ensure Timely Provision and Documentation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquisition, receipt, dispensing, and administration of medications for two residents, including an antiepileptic drug for a resident with epilepsy and dementia. Facility policy required that Schedule II medications be delivered only upon receipt of a faxed or original prescription, allowed emergency use of medications from the emergency supply with pharmacist authorization, and directed that Schedule II medications be reordered when a seven-day supply remained. For Resident 1, who had orders for lacosamide 100 mg by mouth every 12 hours for seizure management, the Controlled Substance Record showed 30 tablets received on December 29, 2025, with administration beginning January 1, 2026, and the last documented dose given on January 15, 2026, at 8:00 PM. The January 2026 MAR documented lacosamide doses on January 16 and 17 as “Hold/See Nurses Note,” and medication administration notes on January 16 and 17 indicated the lacosamide was on order, on back order, and not available, with repeated calls to the pharmacy. On January 17, nursing progress notes documented seizure activity for Resident 1. One note by an LPN at 10:40 PM described a seizure from 10:20 PM to 10:26 PM and stated that the pharmacy had earlier indicated the lacosamide would be sent, but later reported that a prescription was needed to dispense it. Another note by an RN at 11:20 PM documented a seizure lasting approximately 20–25 minutes, notification of the physician, and that the ordered lacosamide was not available, leading to an order to send the resident to the hospital for evaluation and treatment. A written statement from an LPN dated January 28, 2026, indicated that on January 16 the LPN called the pharmacy to report that the resident was out of lacosamide, that it had been ordered days prior, and that the pharmacy said it would be on the next delivery. On January 18, a nurse’s note recorded another seizure for Resident 1 lasting from approximately 7:06 AM to 7:23 AM, physician notification, review of medication concerns with the physician, a new order for Ativan 1 mg IM every 12 hours as needed for seizure activity, and a second transfer to the emergency room. The same note documented that EMS staff were informed of concerns regarding lacosamide, that a voicemail was left for the on-call pharmacist, and that prescriptions for lacosamide and Ativan were later signed and faxed to the pharmacy. Subsequent progress notes indicated that the pharmacy reported the last lacosamide delivery as December 28, 2025, with a 15-day supply, that the pharmacy already had a script for lacosamide, and that lacosamide and Ativan would be included in the next delivery. Resident 1 received a dose of lacosamide from the emergency medication supply on January 18 at 8:00 PM, and a new supply of 60 tablets was received on January 19, with administration resuming that morning. The record showed that Resident 1 had no seizure activity between August 3, 2025, and January 17, 2026, while receiving medications as ordered, and then experienced two seizures with two hospital transfers when lacosamide was not administered as ordered due to the pharmacy’s failure to provide the medication or timely communicate why it could not be supplied when initially ordered. Interviews with the Regional Director of Clinical Services and the DON confirmed that nursing staff had reordered lacosamide on January 12, 2026, that the pharmacy had an active prescription but overlooked filling it, that there was no documentation of pharmacy communication between January 12 and 17, and that staff could not access lacosamide from the emergency supply because the pharmacy would not provide an authorization code while stating there was no current script. For Resident 2, who had dementia and anxiety disorder and an order for Xanax 0.5 mg every 8 hours, a medication administration note on January 26, 2026, documented that Xanax was not administered while awaiting pharmacy delivery. A nurse’s note later that day recorded that an RN contacted the pharmacy about retrieving Xanax from the emergency medication supply and questioned whether two 0.25 mg tablets could be used to equal the ordered 0.5 mg dose; the pharmacy responded that medications must be dispensed as written. The RN then contacted the physician for further orders, and the pharmacy indicated the medication would be on the next delivery. Another note documented that the physician gave a one-time order for Xanax 0.25 mg, two tablets now. The Controlled Substance Record for Xanax showed the prescription was filled on January 25, 2026, but the Receipt Verification section was blank, and the first dose from that package was not administered until January 26 at 6:30 PM. In an interview, the DON stated she expected medications to be reordered when down to a five-day supply, expected timely dispensing and delivery or immediate notification of issues from the pharmacy, and expected staff to complete the Receipt Verification on controlled substance records. No additional information was provided regarding when staff reordered Xanax or the reason for the delivery delay.
Failure to Prevent Accident Hazard and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified when a resident with dementia and hypertension experienced an unwitnessed fall in the Love 2 Lounge. The resident was found on the floor in front of her wheelchair in a semi-Fowler's position. Review of the clinical record and fall incident report showed that there were no predisposing environmental factors noted at the time of the fall. Multiple staff witness statements indicated that the resident was last seen in various locations after dinner, but none reported witnessing the fall or being present at the time it occurred. The resident's care plan included an intervention to assist her to her room after dinner to prevent falls, which had been initiated prior to the incident. The facility's dinner schedule indicated staggered mealtimes across different lounges, and staff statements did not confirm the resident's whereabouts at the time of the fall. The fall incident report did not include any staff witness statements confirming that the resident was still eating dinner when the fall occurred, although the Nursing Home Administrator and DON later stated that she was. The lack of adequate supervision and failure to ensure the resident was assisted to her room after dinner, as outlined in her care plan, contributed to the occurrence of the fall.
Failure to Provide Adaptive Feeding Devices and Meal Assistance
Penalty
Summary
The facility failed to provide adaptive feeding devices and appropriate meal assistance for a resident diagnosed with dementia and heart failure. Clinical record review showed physician orders for the resident to have foam handled utensils at all meals and to have food cut up, as well as a care plan intervention to provide adaptive equipment as ordered. During observation at lunchtime, the resident did not have foam handled utensils and their food was not cut up, contrary to both the physician's orders and the care plan. Another resident at the table was observed cutting up the food for the affected resident. The lunch tray ticket also indicated the need for foam handled utensils, but these were not provided. The Nursing Home Administrator confirmed that the resident should have received the adaptive utensils and meal assistance as ordered.
Failure to Prevent Elopement of High-Risk Resident Due to Lack of Effective Safety Measures
Penalty
Summary
The facility failed to implement interventions, supervision, and effective safety measures to prevent the elopement of a resident who was identified as being at high risk for elopement and exhibited ongoing exit-seeking behaviors. The resident had a history of alcohol-induced persisting dementia and Alzheimer's disease, and was admitted to the facility following a hospital stay where elopement precautions, including a sitter, were required. Upon admission, the resident was assessed as high risk for elopement, with care plan interventions suggested, but documentation shows repeated episodes of exit-seeking, agitation, and attempts to leave the facility, with staff redirection efforts proving ineffective. Despite the resident's documented behaviors and high-risk status, the facility did not implement electronic monitoring devices or other effective interventions to prevent elopement. The resident ultimately exited the locked unit by following or being let out by a visitor or staff member who entered the exit code, as the facility allowed visitors to know and use the exit codes independently. The front lobby doors were not locked from the inside, and the area was not routinely monitored, especially after hours when administrative staff were not present and the receptionist position was vacant. The resident was missing for approximately 17.5 hours before being found by emergency personnel with injuries to the forehead. The investigation revealed that no alarms sounded and nothing alerted staff to the resident's exit. The facility had discontinued the use of electronic monitoring devices (wanderguards) for residents on the locked unit, despite multiple residents being identified as at risk for elopement. Sixteen additional residents were also identified as being at risk for elopement, placing them in an immediate jeopardy situation due to the lack of effective safety measures and supervision.
Failure to Monitor and Communicate Nutritional Status
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of acceptable nutritional parameters for three residents, leading to significant weight loss and inadequate physician notification. Resident 17 experienced a significant weight loss of 28 pounds over several months, which was not properly addressed due to missed weekly weight checks and lack of physician notification. The resident's diet was downgraded to puree without reassessment by speech therapy, and the resident's POA was not interested in supplementation, contributing to the ongoing weight loss. Resident 28 also experienced issues with weight monitoring, as daily weights were not consistently documented, and significant weight gains were not reported to the physician as required. The resident had a history of heart failure and chronic kidney disease, necessitating careful fluid balance management. Despite orders for daily weight monitoring, there were multiple instances where weights were either not recorded or not communicated to the physician, leading to a lack of timely medical intervention. Resident 58, diagnosed with dementia and heart failure, experienced significant weight loss over several months. The facility failed to document physician awareness or evaluation of the weight loss, despite it being discussed in QAPI meetings. The resident's weight loss was attributed to diuretic therapy, but there was no evidence of physician involvement in addressing the issue. The facility's failure to consistently monitor and communicate weight changes to physicians resulted in inadequate management of the residents' nutritional and hydration needs.
Plan Of Correction
1. R17 corrected with new order in an effort to advance diet texture, along with double portions of protein with each meal. R28 and R58 missing weight and documentation was corrected and MD notification was made aware of current weight along with dietician. All residents continue to reside at the facility. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON and/or Dieticians will conduct an order review by March 14, 2025, to identify any residents that have orders for daily weights perimeters to notify the MD with weight changes to also ensure they are appropriately calculated based on weight and medical diagnosis and following the dietitian comprehensive nutrition assessment. A facility-wide audit will be conducted by the dietician and DON for any resident identified with missing documentation, missing MD notification, and physician orders not followed up on by March 14, 2025. 3. DON will educate the Dietitian to fill out a communication form upon a significant weight gain over 30 days, 3 months, and 6 months to be given to the DON and placed in the MDs review folder. In the daily standup meetings, the dietitian notes will be reviewed for significant weight loss/gain with the IDT team to ensure communication and MD notification is implemented and documented timely in the Treatment Administration Record. The DON will also educate the Rehab Department on documenting refusals as evidenced in speech therapy to ensure consult or supplements were discussed with the physician and documented in the EHR (PCC) by March 14, 2025. The DON and Dietician will educate all nursing staff and the IDT team on the policy and procedure of nutrition and hydration status maintenance of the clinical process of fluid and dietary status per individual resident to monitor fluctuations that would be anticipated and may trigger significant weight loss/gain by March 14, 2025. 4. An audit of all residents will be conducted to ensure weights are being completed according to physician orders, therapy refusals are being conducted, and ensuring documentation is completed weekly x 4 then monthly x 2 by the DON and/or Dietitian to ensure the resident has no signs of significant weight loss, until 100% compliance is achieved. The findings of the audits will be reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.
Deficiencies in Transfer Notice Compliance
Penalty
Summary
The facility failed to comply with the notice requirements before transferring or discharging residents, as outlined in 42 CFR Part 483, Subpart B. Specifically, the facility did not provide adequate notice of transfer for two residents who were hospitalized, and the notices for five other residents lacked required information. The deficiencies were identified during a review of clinical records and staff interviews. Resident 1, diagnosed with heart failure, chronic kidney disease, and hyperlipidemia, was transferred to the hospital due to an acute medical change. The notice provided to Resident 1's representative was missing several required mailing addresses, including those for the entity receiving appeal requests and the Office of the State Long-Term Care Ombudsman. Similar deficiencies were found in the notices for Residents 28, 52, 58, and 69, who were also transferred to hospitals for various medical conditions, including dementia, hypertension, and heart failure. Additionally, Resident 28's clinical record lacked a notice of transfer for one of their hospitalizations, and Resident 53's record showed no evidence of a transfer notice being provided for a hospital evaluation following a fall. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of required information on the transfer notices and the failure to provide proper documentation for some transfers.
Plan Of Correction
1. Unable to retroactively correct the clinical record for Residents 1, 28, 52, 53, and 58 with a notice upon transfer that included required and revised information. All residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice. 2. All residents have the potential to be impacted. R1, R28, R52, R53, and R58 will be given the revised Transfer or Discharge form with the appropriate notice of information no later than March 14, 2025 for any immediate Transfer or Discharge, along with a facility-wide audit conducted by the DON and Shift Supervisors. 3. DON will educate the Shift Supervisors by March 14, 2025 upon emergent transfer to the hospital and will provide the revised Notice of Resident Transfer or Discharge form to resident and document in a progress note via the EHR system (PCC) to reflect it was presented with appropriate information. The Shift Supervisor is to then complete a progress note documenting the notice was provided and to whom. The DON will also educate Shift Supervisor on the updated Notice of Resident Transfer on Discharge form, and to provide the Notice of Resident Transfer to Discharge Form to the Resident revealing the mailing address of the entity, which receives request for appeals, mailing address of the Office of the State Long Term Care Ombudsman for protection and advocacy of individuals with developmental disabilities and mental disorders. The DON will in-service the Shift Supervisors by March 14, 2025 to ensure the representative is provided the notice and signed the form when received. DON will also educate the Social Worker by March 14, 2025 to send a 30-day log of transfer and discharges to the local Ombudsman's email box. 4. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent transfer to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge information contained appropriate information and was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Deficiency in Bed-Hold Notice Provision
Penalty
Summary
The facility failed to provide the required bed-hold notices upon transfer or discharge for several residents, as evidenced by clinical record reviews and staff interviews. Specifically, two residents did not receive a copy of the facility's bed-hold notice upon transfer or discharge, and five residents received notices that lacked necessary information. The missing information included the duration of the state bed-hold policy and the reserve bed payment policy, which are required by regulations. Resident 1, who had diagnoses including heart failure and chronic kidney disease, was transferred to the hospital, but the bed-hold notice provided did not include the required information about the state bed-hold duration or reserve bed payment. Similarly, Resident 28, with diagnoses of heart failure and dementia, was transferred multiple times without receiving complete bed-hold notices. In one instance, the facility failed to provide any bed-hold notice at all. Staff interviews confirmed these omissions and acknowledged the failure to include necessary details in the notices. Additional residents, including Residents 52, 53, 58, and 69, also experienced similar deficiencies. Resident 52, with hypertension and diabetes, was transferred to the hospital, but the notice lacked information on the state bed-hold duration and reserve payment. Resident 53, who suffered a fall, did not receive a bed-hold policy notice upon transfer. Resident 58 and Resident 69 also received incomplete notices, missing critical information about the bed-hold policy. Staff interviews further confirmed these deficiencies, highlighting a systemic issue in the facility's handling of bed-hold notices.
Plan Of Correction
1. Unable to retroactively correct the clinical record for R28 and R53 to provide clinical record of the facility's bed-hold notice upon date of transfer or discharge from the facility. Both residents continue to reside at the facility. Unable to retroactively correct the clinical record for R1, R28, R52, R58 and R69 to provide bed-hold notices that included the required information upon transfer; residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice. 2. All residents have the potential to be impacted. R1, 28, 52, 53, and 58 immediately will be given the form regarding Bed Hold Notice regulation no later than March 14, 2025 or any need for bed hold notice immediately of Transitions of Care Policy and Procedure, Admission, Transfers, and Discharge for the Resident and/or Resident Representative. R69 no longer resides at the facility, no adverse effects related to practice. 3. Facility wide Audits of all bed hold transfers or discharges for the past 3 months will be conducted by the DON and/or Shift Supervisor. Any residents who do not have the appropriate information on the bed transfer form will be given a new form with the revised information by March 14, 2025. 4. The DON will in-service the Shift Supervisor upon emergent transfer to the hospital to provide the Notice of Bed Hold form to the resident by March 14, 2025. The Shift Supervisor is to then complete a progress note stating it was provided, and to whom. DON will educate the Shift Supervisors on the revised Notice of Bed Hold Form to the resident upon emergent transfer to the hospital, and document in a progress note in the EHR (PCC) System that it was given. 5. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent bed-hold notices upon transfer or discharge to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge form was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Care Plan Deficiencies in Resident Participation and Documentation
Penalty
Summary
The facility failed to ensure the participation of residents in the care planning process and did not adequately review and revise care plans for several residents. Resident 4 was not invited to care plan meetings, as confirmed by both the resident and the Nursing Home Administrator (NHA). Despite having multiple care conferences, there was no documentation of Resident 4's attendance or invitation, which is against the facility's policy that supports resident participation in care planning. Resident 28's care plan did not include documentation of a skin rash or interventions for its treatment, despite the resident having a rash for about six months and receiving treatment for it. Additionally, Resident 28 expressed a preference for wearing a bra, which was not addressed in the care plan. The NHA acknowledged that the care plan was not updated upon the resident's re-admission after a hospital discharge, leading to missing personalized care information. Resident 37 also had a skin rash that was not documented in their care plan, despite having physician orders for treatment. Similarly, Resident 58's care plan lacked documentation of antipsychotic medication use and the target behaviors it was intended to manage. The Director of Nursing (DON) confirmed that these omissions were not in line with the facility's expectations for care plan documentation.
Plan Of Correction
R4 unable to retroactively correct care plan. R4 was recently offered to participate in the care planning process and declined on 2/19/25 invited by the Activities Director, documented on clinical record of resident's choice to decline. R4 acknowledged understanding of residents right to participate in the care planning process. R28 unable to retroactively correct clinical record of the presence of the rash, it is confirmed the rash was resolved. R28 care plan was reviewed and updated to reflect all care areas specific to the resident preferences, such as wearing a bra daily. Section V of the MDS care area assessment summary for R28 was also updated for assistance with eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and mobility, along with preference of importance to choose clothing. R28's care plan specifics for ADL self-care performance also reviewed for additional interventions and updated. R37 care plan for rash was updated on 2/6/25 for the treatment of the rash. R58 care plan was updated on 2/17/25 to reflect the antipsychotic medication was being utilized to manage residents identified targeted behaviors and on 2/5/25 it was indicated on the R58's care plan that it was updated to reflect antipsychotic use. R4, R28, R37 and R58 currently reside at the facility and no adverse effects related to practice. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON, Shift Supervisors, Social Services, Activities Director and MDS Coordinator will audit all care plans to ensure the comprehensive care plans are being updated or new care plans completed for all residents including readmissions from hospital to reflect individual preferences and Resident-specific ADL information to include interventions by March 14, 2025. To prevent other residents from being affected the DON will re-educate the Social Services and Activities Director, Activities Director and Shift Nurse Supervisors by March 14, 2025 on the requirements and policy of the Comprehensive Care Plan and quarterly review assessments, as well as compliance with the Care Plan Revisions. Additional training to include residents right to be invited to Comprehensive Care plans and document that the invite was offered or refused, along with documentation that resident understands and acknowledges their rights to attend care plan meetings. The DON will also educate on directives of physician orders, documenting the identification of any medical concerns or progress along with interventions and treatment follow up for residents. The DON and NHA will also in-service the IDT Team on communication of any new information or updates in the daily standup and clinical meetings to include, change of condition or significant change to be updated in the resident's care plan. An audit will be conducted by the DON, Activities and/or Social Services Director to ensure comprehensive care plans and assessments are completed timely, updated/revised for all residents weekly x 4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor possible side effects and target behaviors for two residents who were prescribed psychotropic medications. Resident 53, diagnosed with dementia and hypertension, was prescribed Abilify for hallucinations. However, the monitoring for side effects was incorrectly documented as for an anti-depressant, not an antipsychotic, and did not include specific side effects such as unsteady gait and tardive dyskinesia. Additionally, there was no documented monitoring of Resident 53's targeted behaviors or hallucinations. Resident 58, diagnosed with dementia, anxiety disorder, and depression, was prescribed multiple psychotropic medications, including quetiapine, Ativan, and Cymbalta. After being hospitalized, the monitoring for potential side effects and target behaviors was not resumed upon their return. The care plan for Resident 58 did not document the use of antipsychotic medication, potential side effects, or identified target behaviors. The DON confirmed that these elements should have been included in the care plan and monitored accordingly. Interviews with the DON and NHA revealed that the facility's practice did not include documenting and tracking behaviors on a resident's Medication or Treatment Administration Record. The oversight in monitoring and documentation was acknowledged, and it was confirmed that the necessary monitoring should have been in place for both residents to ensure proper management of their psychotropic medication use.
Plan Of Correction
1. R53 potential side effects monitored for behaviors was corrected in the clinical record, care plan updated and resident continues to reside at the facility. R58's potential targeted behavior side effect is being monitored, corrected in the clinical record, care plan updated for behaviors and resident continues to reside at the facility. 2. The facility lacked evidence of side effect monitoring for the residents' individual psychotropic medications and monitoring of target behaviors for unnecessary psychotropic medications. The facility has determined that all residents prescribed psychotropic medication have the potential to be affected by this alleged deficient practice. DON is currently monitoring R53 and R58 prescribed psychotropic medication for side effects and targeted behaviors and will be conducting a facility wide audit by March 14, 2025 with the Shift Supervisors to review and ensure side effects and targeted behaviors are in place and documented in the medical record for each individual resident. 3. DON will re-educate clinical management on monitoring possible side effects and target behaviors for all residents on psychotropic medication by March 14, 2025. Routine GDR meetings are currently being held monthly by the DON, NHA, shift supervisors, medical director, IDT staff members, and Pharmacy Consultant for review. 4. The NHA, DON and Medical Director will conduct 3 random audits of at least five residents receiving psychotropic medication to ensure side effects are monitored. The audit will be conducted once a week for 4 weeks then monthly for 2 months until substantial compliance is achieved or as otherwise determined by the findings reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.
Failure to Record Dish Machine Temperatures
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not consistently recording dish machine temperatures in the main kitchen. The review of the Dish Machine Temperature Logs revealed numerous instances where temperatures were not recorded during various meal periods across several months, including May, June, July, August, September, October, November, December 2024, and January 2025. Specifically, there were no temperature recordings for dinner throughout these months, and some logs for June and July 2024 were missing entirely. An interview with the Food Service Director indicated that the lack of supervision during dinner might have contributed to the failure to log temperatures. The Nursing Home Administrator confirmed that it is the facility's expectation to utilize kitchen equipment according to professional standards, highlighting a discrepancy between expected practices and actual operations. This deficiency in maintaining proper food safety protocols was identified through staff interviews and documentation reviews.
Plan Of Correction
1. The dish machine temporary log and utilizing kitchen equipment has been corrected and the NHA educated (E8) Food Service Director and dietary staff immediately on the professional standards for food service safety in the main kitchen, including logging the dishwasher temperatures. 2. The facility has determined that all residents have the potential to be affected by this alleged deficient practice. No adverse effects related to the deficiency cited. 3. The Food Service Director (E8), Assisted Food Director and dietary staff were educated immediately by the NHA and will continued to be monitored by March 14, 2025 and observed by the NHA on utilizing professional standard kitchen equipment for food service safety and logging the dish machine temperature during all meal periods. 4. The Food Director and Assistant Director of Dining Services will be auditing the dish machine logs during each meal period and the dish machine log along with the dinner cook weekly x 4 weeks then monthly x 2 months by the NHA and/or Vice President of Facilities. This plan of correction will be monitored at the monthly QAPI meeting until such time consistent substantial compliance has been met.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for three residents. Resident 17 experienced a significant weight loss of 31 pounds over six months, but the Quarterly MDS inaccurately marked the weight loss question as "no or unknown." This discrepancy was confirmed by the Nursing Home Administrator (NHA) and was acknowledged to be an error that required modification. Resident 28's clinical record showed conflicting information regarding weight changes following a hospital stay. Initially, a nutrition note indicated significant weight gain, but a later entry corrected this to significant weight loss. The Medicare 5 Day MDS did not reflect this weight loss, and during an interview, the dietician confirmed the MDS was inaccurately coded. Resident 58's Quarterly MDS failed to indicate the presence of a urinary catheter, despite physician orders and treatment records confirming its use. The NHA confirmed this coding error, acknowledging the need for correction.
Plan Of Correction
1. R17 quarterly MDS was corrected to reflect weight loss, R28 Medicare 5 Day MDS was corrected to reflect weight loss and R58 quarterly MDS was corrected to reflect urinary catheter. All residents reside at the facility. No adverse effects related to practice. 2. All residents have the potential to be impacted. The MDS Coordinator will conduct a facility audit of the most recent completed MDS assessments for all residents to identify correct coding of weight/loss/gain and correct coding of indwelling catheter by March 14, 2025. Any coding errors identified in the audit will be corrected as well. 3. DON and/or NHA to educate the MDS Coordinator by March 14, 2025 on Section K, Swallowing and Nutritional Status of the RAI Manual; and Section H Bowel and Bladder of the RAI Manual that includes the importance of thoroughly reviewing the medical record prior to completing the MDS Assessment. 4. Audits to be completed by the MDS Coordinator for the MDS section K and Section H on 5 residents weekly x4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Failure to Follow Enhanced Barrier Precautions for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and services to promote healing and prevent infection for a resident with a pressure ulcer, as required by professional standards. The deficiency was identified during an observation of wound treatment for a resident diagnosed with dementia and hypertension, who had an unstageable pressure injury on the third toe of the right foot. The facility's policy on 'Enhanced Barrier Precautions' mandates the use of gowns, gloves, and masks during high-contact procedures such as wound treatment to prevent the transmission of multidrug-resistant organisms. During the wound treatment observation, an LPN entered the resident's room wearing a facemask and performed hand hygiene and glove changes but did not wear a gown, contrary to the facility's Enhanced Barrier Precautions policy. The resident was on droplet precautions for influenza, and the Enhanced Barrier Precaution sign was placed on the back of the resident's door. The Director of Nursing confirmed that the resident should have been under both droplet and Enhanced Barrier Precautions, and the LPN should have worn a gown during the procedure to comply with the facility's protocol.
Plan Of Correction
1. R2 no longer resides at the facility. The DON educated E3 immediately on Initiation of Enhanced Barrier Precautions to be obtained for residents with chronic wounds such as pressure ulcers consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This includes all residents under any type of precautions to ensure appropriate signage is posted to reflect as such. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and or IP Nurse and nursing staff by March 14, 2025 to identify residents under any type of precautions to ensure appropriate signage is posted prior to employees entering the room. 3. DON and IP Nurse will educate all staff by March 14, 2025 addressing observance of signs posted on the door to determine PPE precautions and the use of gloves, mask, gown when performing high contact procedures and to ensure gowns and gloves available immediately near or outside of the resident's room. 4. Random Audits will be conducted by IP Nurse and or DON of at least five residents per week for 4 weeks then monthly for 2 months until 100% compliance is achieved or as otherwise determined by Risk Management Team/Quality Assurance Committee to ensure compliance is obtained and maintained.
Failure to Prevent Accidents and Hazards for Residents
Penalty
Summary
The facility failed to prevent accidents and hazards for two residents, leading to deficiencies in their care. Resident 35, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced an unwitnessed fall in the bathroom. The resident's care plan required assistance with toileting and transfers, yet the resident was left alone in the bathroom without the ability to use the call bell due to cognitive limitations. Interviews with staff revealed that the resident did not understand how to use the call bell and would often yell for assistance instead. The Nursing Home Administrator acknowledged that the resident should not have been left alone, and the staff member involved was terminated. Resident 47, diagnosed with dementia and hypertension, was identified as a fall risk with a care plan intervention to have a fall mat placed on the left side of the bed when in bed. However, an observation revealed that the fall mat was not in place when the resident was out of bed, contrary to the care plan instructions. A previous incident note indicated an unwitnessed fall where the fall mat was not in place, and staff had been educated on ensuring the mat was properly positioned. These lapses in following care plans and providing adequate supervision contributed to the deficiencies noted in the report.
Plan Of Correction
1. R35 resides at the facility and R47 no longer resides at the facility, both residents have the potential to be impacted by the deficient practice. The IDT team met and reviewed R35 fall care plan to ensure it reflects appropriate interventions that is appropriate for residents' clinical diagnosis that includes dementia (a brain disorder that causes a decline in cognitive function, memory, and behavior, severe enough to interfere with daily life). 2. Current residents will have their fall risk assessment reviewed and residents identified at risk will have a care plan update to ensure appropriate interventions are in place. This includes conducting a fall mat audit by the DON and Facilities Director to ensure care plans match fall mat policy and resident care needs and positioning of the mat, if deemed necessary to prevent future occurrence by March 14, 2025. 3. A fall packet will be placed on the nursing units that will include a list of possible interventions to initiate post fall. The DON and IDT Team will be re-educating staff on February 26, 2025, on the implementation of interventions immediately post fall and observance of residents who may not be in compliance with call bell protocol or lack awareness of usage to review and guide the team to the appropriate interventions. All falls will be reviewed in the clinical daily meeting with the IDT team to ensure an appropriate intervention has been added to the resident's care plan. 4. Falls that occurred will be reviewed by the DON and clinical team weekly for 4 weeks, then monthly for 3 months to ensure appropriate interventions are initiated, added to the care plan and in place, along with auditing of the use of mats for the individual resident. This plan of correction will be monitored at the monthly Quality Assurance meeting until consistent substantial compliance has been met.
Failure to Assist Resident with Necessary Dental Care
Penalty
Summary
The facility failed to assist Resident 52 in obtaining necessary dental care, specifically the extraction of upper teeth to facilitate the creation of a full-upper denture. Despite a dental consultation conducted on October 21, 2024, which recommended full mouth x-rays (FMX) and an oral surgery consult for extractions, these recommendations were not followed up. As of February 5, 2025, Resident 52 had not received the required dental x-rays or any consultation order for the extraction of his upper teeth. The deficiency was further compounded by the facility's process, where the physician reviews a 'Visit Summary' document to provide orders. This document did not include the specific recommendations from Resident 52's individual dental consultation form, leading to a lack of further treatment or consultation. Resident 52, who has hypertension and diabetes mellitus type two, reported issues with a partial top denture that moved around while eating, indicating a need for the recommended dental procedures.
Plan Of Correction
1. R52 currently resides at the facility and has been added to the recommended identified contracted dental center for the resident's individual dental consult sheet of dental x-rays and surgical consult for extraction of teeth by March 14, 2025. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. Current residents will be reviewed by the DON and Shift Supervisors to ensure that routine dental services are provided when needed and by March 14, 2025. 3. Re-education will be provided by DON to the licensed nursing staff to include routine and emergency dental services per policy by March 14, 2025. 4. DON and Nurse Supervisors will conduct an audit of at least 5 random residents to determine if dental services have been received as necessary. These audits will be done weekly x4 weeks and then monthly x2 until substantial compliance is achieved or as determined by the findings reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.
Infection Control Deficiencies in PPE Use and Precaution Adherence
Penalty
Summary
The facility failed to implement proper infection control measures in two resident care areas, specifically regarding the use of personal protective equipment (PPE) and handling of potentially contaminated items. In one instance, a Licensed Practical Nurse (LPN) was observed not following the facility's policy on contact precautions while treating a resident diagnosed with influenza and an unstageable pressure injury. The LPN placed treatment supplies on the resident's bedside table and later returned unused gauze to the treatment cart, despite the gauze having been in contact with potentially contaminated surfaces. Another deficiency was observed when an employee failed to adhere to droplet precautions for a resident diagnosed with influenza A. The employee did not perform hand hygiene or wear face protection while entering and exiting the resident's room to serve lunch. This was confirmed by the Nursing Home Administrator, who acknowledged that droplet precautions were not followed during the observation. Additionally, a third incident involved an employee not using PPE or performing hand hygiene while entering the room of a resident on contact precautions for scabies. The employee delivered a meal tray to the resident and continued to serve other residents without following the necessary infection control protocols. The Nursing Home Administrator confirmed that employees are expected to follow facility policies regarding contact precautions.
Plan Of Correction
1. R2 no longer resides at the facility. R5 and R25 continue to reside at the facility. E1, E3, and E7 were educated immediately by the DON and IP Nurse on facility policy review to ensure staff implemented infection control policies to prevent the spread of infection by using PPE (personal protective equipment) and educated on how to handle potentially contaminated items to decrease the possibility for transmission of infectious disease for one of one unit treatment carts observed, along with education on Transmission-based (Isolation) precautions "Contact Precautions" to wear a gown for all interactions that may involve contact with residents or potentially contaminated areas in the residents' room and/or environment. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. 3. A Root Cause Analysis was conducted and the cause was determined that the facility staff member E3 failed to implement infection control policies to prevent the spread of infection by not using PPE (Personal Protective Equipment) in R2 care areas while providing wound care to R2, failed to follow droplet precautions to use gloves, mask, eye protection, and gown. Then E3 was also observed moving an unused, unopened pack of gauze from the bedside table to R2's bed, while observed exiting the room, and returning the pack of gauze into the box in the treatment cart from where they were moved. E7 failed to perform any hand hygiene prior to entering residents R5 and R7 rooms to provide lunch on a tray, then proceeded to assist R5 with assistance of lunch. E7 failed to adhere to the droplet precautions on R5 door that revealed resident was on droplet precautions. E1 failed to enter R25's room while resident was on contact precautions and enter R25's room with lunch tray, set it up for R25 to eat then exit the room and continued on taking trays to other residents, exiting R5 room without wearing any face protection upon entering room, and failed to handle potentially contaminated items to decrease the possibility for transmission of an infectious disease from the Love and Love two units, then to one of one unit treatment carts on the Love unit. 4. A facility-wide audit will be conducted by the DON, IP Nurse, and Shift Supervisors by March 14, 2025, to review all residents who have the potential to be affected by this deficient practice. Re-educate all staff (including maintenance, housekeeping, dietary, administration, etc.) on donning personal protective equipment (PPE) upon room entry and discarding before exiting the room which is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. The education will also include identifying, reporting, and prevention of the Transmission-Based (Isolation) accepted national standards and how to use disposable or dedicated noncritical resident-care equipment between residents. The following equipment will be cleaned and disinfected by manufacturers' instructions with an EPA-registered disinfectant after use. The DON and IP Nurse will also educate all nursing staff on moving any unused, unopened pack of gauze from the bedside table to another resident's room, as to not exit rooms and returning the pack of gauze into the box in the treatment cart from where they were removed initially, then to and from residents' room without proper droplet precaution awareness of signage. The DON and IP Nurse will continue to re-educate all staff through March 14, 2025, on donning and doffing PPE to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. 5. The audit will be conducted by the DON and IP Nurse at the rate of 10% weekly until 100% compliance is achieved for three consecutive audits. Then the audit will be conducted monthly for 3 months. If 100% compliance is achieved/maintained, the deficiency will be considered resolved. Results of the audits will be presented by the DON and IP Nurse and discussed at the monthly QAPI meeting to determine the need for further audits and or action plans.
Deficiency in Vaccine Education Documentation
Penalty
Summary
The facility failed to provide evidence that education was given to residents or their representatives regarding the risks, benefits, or side effects of the influenza vaccine. This deficiency was identified for two residents during a review of their clinical records. The facility's policy requires that prior to administering the influenza vaccine, the resident or their legal representative should receive a copy of the CDC's current vaccine information statement and sign a consent form, which should be documented in the resident's medical record. For one resident, the clinical record showed that their representative refused the flu and RSV vaccination, but there was no evidence that the representative was educated on the benefits, risks, or potential side effects of the vaccine. This resident had diagnoses including hypertension, diabetes, and severe dementia. Another resident, who had diagnoses of diabetes, hypertension, and protein-calorie malnutrition, received an influenza vaccine, but again, there was no documentation that education was provided to the resident or their representative. During interviews, the facility's Infection Preventionist stated that they distribute the appropriate Vaccine Information Statement and document consent or refusal in the resident's medical record. However, the Nursing Home Administrator confirmed that the required education and documentation were not provided for the two residents in question, leading to the identified deficiency.
Plan Of Correction
1. R8 and R25 continue to reside in the facility and no adverse effects related to the deficiency as cited. R8 Representative was educated on the benefits, risks and potential side effects of the vaccine and noted on clinical record. R25 Representative gave permission for the Influenza and Pneumococcal vaccine and education of the benefits, risks, or potential side effects of the vaccine is on clinical record and no adverse effects related to this practice were observed. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and IP Nurse to provide evidence that education will be provided to Residents and/or their Representatives on the risks, benefits, or side effects of the influenza vaccine with confirmed documented on the individuals clinical record to reflect consent or refusal. All residents will be offered the pneumococcal and influenza vaccines as part of the facility vaccination program. 3. After completion of the facility wide audit by the DON, IP Nurse and Nurse Supervisors by March 14, 2025 all licensed nurses will be educated on the policy and procedure for offering and documenting immunizations. 4. Once the vaccination program has been implemented, an audit will be conducted weekly to ensure residents have been offered the appropriate vaccines and documentation is completed by the DON and/or IP Nurse. Throughout flu season, new resident files will be audited to ensure vaccination documentation is completed and residents and representatives were educated on the benefits, risks, and potential side effects of the vaccine and noted on clinical record. Results of these audits will be discussed at the monthly QAPI meeting for three months for further review and recommendations.
Failure to Document COVID-19 Vaccine Education for Residents
Penalty
Summary
The facility failed to provide evidence that education on the risks, benefits, or side effects of the COVID-19 vaccine was given to two residents or their representatives. The facility's policy requires documentation of such education in the resident's medical record, but this was not found for two residents reviewed. Resident 8's representative refused the COVID-19 vaccination, but there was no documentation indicating that they were educated on the vaccine's benefits, risks, or potential side effects. Similarly, Resident 25 received a COVID-19 booster, but there was no evidence that the resident or their representative received the necessary education. During interviews, the facility's Infection Preventionist stated that they provide verbal education and distribute Vaccine Information Statements, but do not use consent or declination forms. The Nursing Home Administrator confirmed that education should have been documented for the residents in question. The deficiency was identified based on a review of facility policy, clinical records, and staff interviews.
Plan Of Correction
1. R8 and R25 continue to reside in the facility and no adverse effects related to the deficiency as cited. R8 Representative was educated on the benefits, risks and potential side effects of the Covid-19 vaccine and noted on clinical record as refusal, declination documented. R25 last received the COVID-19 booster vaccine on October 20, 2024 and representative was educated on the benefits, risks and potential side effects of the Covid-19 vaccine, no adverse effects related to this practice were observed. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and IP Nurse to provide evidence that education will be provided to Residents and/or their Representatives on the risks, benefits, or side effects of the Covid-19 vaccine with confirmed documented on the individuals clinical record to reflect consent or refusal. All residents will be offered the Covid-19 vaccine and or booster as part of the facility vaccination program. 3. After completion of the facility wide audit by the DON, IP Nurse and Nurse Supervisors by March 14, 2025 all licensed nurses will be educated on the policy and procedure for offering and documenting immunizations, including the Covid-19. 4. Once the vaccination program has been implemented, an audit will be conducted weekly to ensure residents have been offered the appropriate Covid-19 vaccines and documentation is completed by the DON and/or IP Nurse. Throughout the uptick of the Covid-19 season, new resident files will be audited to ensure the Covid-19 vaccination documentation is completed and residents and representatives were educated on the benefits, risks, and potential side effects of the Covid-19 vaccine and noted on clinical record. Results of these audits will be discussed at the monthly QAPI meeting for three months for further review.
Infection Control Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure the presence of three required multidisciplinary members at the Infection Control Committee meetings, as mandated by the Medical Care Availability and Reduction of Error (Mcare) Act. Specifically, laboratory personnel, physical plant personnel, and a community member were absent from these meetings. The review of the facility's attendance records for the Quality Assurance Performance Improvement (QAPI) and Infection Control meetings revealed that during the second, third, and fourth quarters of 2024, these members did not attend any of the monthly meetings. During an interview, the Nursing Home Administrator confirmed that the facility holds these meetings monthly and attempts to have all required attendees present at least once per quarter. However, she acknowledged that the required members failed to attend as expected. She also mentioned that the absence of Physical Plant Personnel was due to instructions from the corporate office, which indicated that their attendance was not necessary.
Plan Of Correction
1. The facility was evaluated on the review of the facilities' Infection Control Committee attendance records to ensure this standard of operation set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents were being followed by all attendees present on a monthly basis. The Infection Control Committee meeting includes Medical Staff, Nursing Staff, Administration, laboratory personnel, physical plant personnel, Safety Officer, and a community member. Attendance will be mandated accordingly and deficiency corrected by March 14, 2025. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. The Infection Control Committee will continue to meet monthly to ensure an Infection Control plan as stated is developed and implemented that includes a multidisciplinary committee, including representatives from each of the specific health care facility to include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, community member, laboratory personnel, pharmacy staff, and infection control team members. 3. All Infection Control Committee members will be re-educated on monthly mandated attendance to ensure three of nine required multidisciplinary members are present to meet compliance standards and regulation by March 14, 2025. The NHA will invite the committee a month before the next meeting and send reminders out a week prior to the scheduled meeting date to ensure 100% participation is achieved. 4. The NHA will conduct monthly audits for 3 months to ensure attendance of members. If 100% compliance is achieved/maintained, the deficiency will be considered resolved. Results of the audits will be presented by the NHA and discussed at the monthly QAPI meeting to determine the need for further audits and/or action plans.
Failure to Implement Effective Infection Control Practices for Scabies
Penalty
Summary
The facility failed to implement effective infection control practices to prevent or limit the spread of infectious diseases, specifically scabies, among its residents. The deficiency was identified through a review of clinical records, CDC guidance, facility documentation, and staff interviews. The facility did not have a specific policy or procedure for scabies and relied on CDC guidance for managing outbreaks. Despite identifying an increase in skin rashes among residents since December 2023, the facility did not conduct skin scrapings to confirm scabies, except for one resident whose condition was confirmed in November 2024. The facility's documentation revealed that 23 residents were monitored for skin rashes, with 16 still experiencing rashes at the time of the survey. The Director of Nursing confirmed that only two residents were on contact precautions for scabies, and no skin scrapings were conducted for other residents with rashes. The facility lacked the means to collect skin scrapings, and no assessments or tracking of skin conditions were implemented for some residents, despite complaints of rashes. The Nursing Home Administrator stated that the facility was expected to follow CDC guidelines after scabies were identified. However, the facility failed to implement isolation and infection control practices for residents with undiagnosed rashes after a confirmed case of scabies. This lack of action and failure to secure testing for residents with rashes contributed to the deficiency in infection control practices.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a resident with dementia and hypertensive heart disease, who was struck by a staff member during an attempt to clean the resident. According to witness statements, the resident became combative and hit the staff member, who then retaliated by hitting the resident twice, including a punch to the face. This incident was reported by another staff member, and the resident was subsequently transported to the hospital for evaluation, returning with no identified concerns. Observations following the incident revealed that the resident had light bruising to the outer aspect of the right eye. The facility's policy on abuse, neglect, and exploitation, which was last revised in June 2024, emphasizes the protection of residents' health, welfare, and rights by prohibiting abuse. During an interview, the Nursing Home Administrator confirmed that it is the facility's expectation that residents are free from abuse.
Failure to Assess Resident's Rash
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with skin issues. The resident, who had diagnoses of dementia and hypertension, was reported by their family to have rash-like areas on their right arm. A physician ordered hydrocortisone cream to be applied twice a day as needed. However, there was no assessment documented in the resident's clinical record that described the characteristics of the rash, such as its size, presentation, or area. The Director of Nursing confirmed the absence of an assessment, and the Nursing Home Administrator stated that it was the facility's expectation that the rash would have been assessed when identified.
Failure to Notify Hospice of Change in Resident's Condition
Penalty
Summary
The facility failed to timely notify hospice of a significant change in condition for a resident who was under hospice care. According to the facility's policy and the hospice contract, the facility is required to inform hospice immediately when there is a significant change in a resident's physical, mental, social, or emotional status. The resident in question had been admitted to hospice with a primary diagnosis of interstitial pulmonary disease and had orders for oxygen at 5 liters via nasal cannula. On the night of the incident, the resident's oxygen saturation levels dropped significantly, reaching as low as 48% while on 5 liters of oxygen, yet hospice was not contacted until the following morning. The nursing progress notes and medication administration records indicate that the resident received morphine for comfort during this period of low oxygen saturation. Despite the critical drop in oxygen levels, hospice was only contacted after a representative of the resident requested it the next morning. Interviews with the Director of Nursing and a registered nurse confirmed that the low oxygen saturation could have indicated the resident was starting to decline and transition, and the Nursing Home Administrator acknowledged that hospice should have been contacted during the night when the resident's oxygen saturation was critically low.
Failure to Monitor and Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four residents, resulting in actual harm due to continued weight loss. Resident 22 experienced a significant weight loss of 17.7 pounds within a short period, and no nutritional assessment or interventions were put in place until two weeks later. The facility did not have dietitian coverage during this period, and nursing staff failed to notify the physician promptly or consult the corporate Certified Dietary Manager for assistance. Resident 23 also experienced significant weight loss over several months, with no nutritional assessments completed since their admission. Despite an increase in nutritional supplements, the resident's weight continued to decline. The facility was without a dietitian for several months, and the Director of Nursing was responsible for reviewing weights and addressing concerns but failed to do so. The facility did not contact the corporate Certified Dietary Manager for assistance during this time. Resident 45 experienced a significant weight loss of 13.5 pounds over a few months, with no nutritional assessments or interventions documented until much later. The facility did not have a dietitian during this period, and nursing staff failed to notify the physician or responsible party of the weight loss promptly. Resident 57 experienced a significant weight gain, but no nutritional assessment was completed following the change. The facility did not have dietitian coverage, and nursing staff failed to notify the physician or consult the corporate Certified Dietary Manager for assistance.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella. The facility's policy, dated October 23, 2022, stated that a water management team was established to develop and implement the program, and that the Maintenance Director would maintain documentation describing the facility's water system. Additionally, a risk assessment was to be conducted annually by the water management team. However, the facility was unable to provide an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, nor could they provide evidence of measures to prevent the growth of these pathogens and how to monitor them. During an interview, the Nursing Home Administrator confirmed that the facility had not implemented a water management program.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident 6, who has diagnoses including dementia, legal blindness, and generalized anxiety disorder. The resident's care plan specified that food should be placed in individual bowls and arranged consistently on the tray to enhance the resident's ability to feed herself. Additionally, the care plan indicated that the resident preferred to have her cell phone within reach while awake. However, observations on multiple occasions revealed that the resident's cell phone was across the room charging on a table, and the arrangement of food on her tray was inconsistent, with items placed in different positions on different days. During interviews, the Nursing Home Administrator acknowledged that the resident's meal tray should be set up with the bowls arranged in a clockwise manner and that the cell phone should be within reach when the resident is awake. These observations and interviews indicate that the facility did not adhere to the care plan, resulting in a failure to accommodate the resident's needs and preferences as outlined in her care plan.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' statuses for six of the 19 residents reviewed. Resident 6's Quarterly MDS inaccurately indicated that she was receiving hospice services, despite hospice services being discontinued in December 2023. This error was confirmed by the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator (NHA). Resident 7's MDS incorrectly marked that the resident was not taking antipsychotic or anticoagulant medications, despite daily administration of Olanzapine and Xarelto as per the Medication Administration Record (MAR) for February 2024. This discrepancy was acknowledged by the NHA during an interview. Resident 8's quarterly MDS inaccurately indicated the use of physical restraints, which was not supported by clinical records or observations. The NHA confirmed that Resident 8 did not have a physical restraint. Resident 22's MDS was incorrectly coded for the number of falls with injury, marking an injury (except major) that did not occur. The RNAC and NHA both confirmed this coding error. Resident 33's MDS failed to include the use of a CPAP machine for sleep apnea, despite a physician's order for its use. This omission was confirmed by the NHA and RNAC. Resident 41's Annual and Quarterly MDS assessments inaccurately coded the use of a CPAP machine, despite physician orders indicating its use. This error was also confirmed by the NHA and RNAC. These inaccuracies in the MDS assessments were identified through clinical record reviews and staff interviews, highlighting a pattern of errors in documenting residents' statuses accurately.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for three residents were updated upon changes in their conditions. Resident 29 had a care plan for a pressure ulcer that was not updated when the ulcer resolved. Despite the wound assessment indicating the resolution, the care plan remained active. The Nursing Home Administrator (NHA) acknowledged that the care plan should have been updated accordingly. Resident 53's care plan included interventions to prevent falls, such as ensuring appropriate footwear. However, observations revealed the resident was often barefoot, and the care plan did not reflect the resident's tendency to remove their socks. The NHA confirmed that the care plan should have included this behavior. Resident 60 had an active care plan for oxygen therapy, but observations and record reviews showed no current need for oxygen, and the care plan was not updated to reflect the discontinuation of oxygen therapy. The NHA confirmed that the care plan should have been resolved.
Failure to Follow Care Protocols and Inconsistent Wound Documentation
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for four residents. For Resident 7, the Licensed Practical Nurse (LPN) did not follow proper hand hygiene protocols during a dressing change for a moisture-associated skin damage (MASD) wound. The LPN did not change gloves or perform hand hygiene after cleansing the wound and before applying the medical grade honey, which is against the facility's Dressing Change Policy. Additionally, the resident did not have a dressing in place as ordered, which the LPN attributed to the resident being incontinent and the dressing being removed by a nurse aide prior to the dressing change observation. Resident 22, who had a history of dementia and a fracture of the left forearm, was observed multiple times without the required splint device. The facility failed to obtain a physician's order for the splint upon the resident's return from the hospital, despite it being included in the hospital discharge summary. The resident's care plan included the use of the splint, but it was not consistently applied, and the family had declined orthopedic follow-up, opting for comfort care instead. The facility acknowledged the oversight and planned to clarify the need for the splint with the physician. Resident 45 had a wound on the left great toe that was inconsistently documented and classified. Initially identified as a pressure injury, the wound was later documented as trauma-related and then as an arterial ulcer, despite arterial studies showing no significant peripheral artery disease. The wound was reported as resolved, but staff continued to document on the area due to the presence of a scab. The facility's communication and documentation regarding the wound were unclear and conflicting, leading to inadequate follow-up. Additionally, Resident 67, who had a urinary tract infection (UTI), did not have vital signs monitored every shift as care planned, which the Nursing Home Administrator (NHA) confirmed was an expectation that was not met.
Failure to Consult Qualified Dietary Staff for Nutritional Assessments
Penalty
Summary
The facility failed to consult qualified dietary staff to assess the nutritional needs of residents in the absence of a qualified dietitian for four of 17 residents reviewed. During the initial tour of the kitchen and pantries, it was revealed that the Dietary Manager was off, the Dietitian was new, and her schedule was uncertain. Interviews with the Nursing Home Administrator and the Dietary Manager confirmed that the facility had been without a Dietitian from October 2023 until March 5, 2024. During this period, neither the Dietary Manager nor the cook could assess residents' nutritional needs or status, and the facility did not consult the corporate Certified Dietary Manager as they should have. Clinical record reviews for Residents 22, 23, 45, and 57 revealed significant gaps in nutritional assessments. Resident 22, diagnosed with dementia and dysphagia, had no nutritional assessment between September 15, 2023, and March 20, 2024. Resident 23, diagnosed with dementia and anemia, had only one nutritional assessment at admission in July 2023, with the last dietitian documentation in August 2023. Resident 45, diagnosed with dementia and dysphagia, had no nutritional assessments between September 20, 2023, and March 6, 2024. Resident 57, diagnosed with dementia and vitamin D deficiency, had no nutritional assessment between September 15, 2023, and March 20, 2024. The absence of qualified dietary staff to conduct these assessments during the specified period led to the identified deficiency.
Failure to Store Food and Monitor Equipment Properly
Penalty
Summary
The facility failed to store food and monitor equipment in accordance with professional standards for food service safety in the main kitchen and two pantry areas. Observations revealed multiple instances of undated food items, including gelatin mixes, stuffing mixes, and strawberry mousse mix in the dry storage area. In the main walk-in refrigerator, there were undated cut vegetables, a container of sweet and sour sauce with a partially open lid, a bucket of pickles with a black substance around the lid, and expired yogurts. The walk-in freezer contained undated donut holes, pie shells, and expired cupcakes and pumpkin pies. Additionally, individually prepped cups of brown sugar and open containers of cinnamon sugar, donut glaze, and margarine were not labeled with dates. The facility also failed to properly monitor the concentration of the sanitizing solution in the three-compartment sink, which was found to be around 100 ppm, below the required 272-700 ppm. Employee 9, a cook, was unaware of the correct concentration and confirmed that the concentration was not logged. The dishwasher temperature log was incomplete, with only two days logged for March 2024. In the Faith pantry area, undated individual cookies were found, and the temperature log had multiple missing entries. Similarly, the Love pantry area had undated cereal boxes and an incomplete temperature log. Interviews with the Nursing Home Administrator (NHA) and the Dietary Manager confirmed that the facility's policies were not being followed. The NHA acknowledged that food and beverages should be labeled and dated, and kitchen equipment should be stored and utilized according to professional standards. The Dietary Manager confirmed the expectation for labeling and dating per facility policy and logging the ppm of the sanitizing solution. The NHA also confirmed that the facility should not use conflicting temperature logs and should log temperatures daily.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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