Midtown Oaks Health & Rehab Center

Penalty

No penalty information released

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

Summary

The facility failed to follow physician's orders for three residents. One resident had multiple surgical wounds on both calves, and the order required cleansing the wounds with normal saline before applying oil emulsion gauze, collagen particles, ABD pads, and rolled gauze daily. During observed wound care, an LPN used wound cleanser on the old dressing, removed the dressing, and then applied the ordered wound materials, but did not cleanse the wounds with normal saline as ordered. The LPN confirmed she should have used normal saline and did not. The DON also confirmed the wounds should have been cleansed with normal saline per the physician's order and were not. Another resident with venous ulcers to the left lower leg had an order for ACE wraps to be applied to the left lower leg in the morning and removed in the evening. On multiple observations, the resident was sitting in a wheelchair beside the bed while the ACE wraps were lying on the blankets at the bottom of the bed and were not on the left lower leg as ordered. The resident stated that she is to wear the ACE wraps when out of bed and that some staff put them on and some do not. A nurse aide confirmed the wraps were not on the resident's leg and stated she did not realize they were to be on the resident. A third resident with diabetes had an order for 26 units of Insulin Lispro once daily, to be held if blood sugar was less than 100 mg/dL, but the MAR showed the insulin was administered on several occasions when blood sugars were below that threshold. The DON confirmed there was no documented evidence that the insulin had been held as ordered.

Penalty

No penalty information released

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

Summary

The facility failed to follow physician's orders for one resident with a feeding tube. The resident's admission MDS dated January 26, 2026 indicated cognitive impairment, dependence on staff for daily care tasks, and the presence of a feeding tube. The care plan dated January 21, 2026 directed staff to administer tube feeding as ordered. Physician's orders dated January 21, 2026 specified Isosource tube feeding continuously at 65 cc per hour for 20 hours per day via feeding tube pump and required staff to record the amount of formula provided every shift. Although the MARs for January and February 2026 showed that tube feeding was administered, there was no documentation of the amount of formula provided every shift as ordered. The DON confirmed on February 27, 2026 that staff were not documenting the amount of formula provided every shift and should have been.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accountability of controlled medications for two residents. One resident was cognitively intact, had frequent pain, received PRN pain medication, and had an order for oxycodone 5 mg every 6 hours as needed for severe pain. Review of the controlled drug record for January and February 2026 showed staff signed out oxycodone on four occasions, but the resident's MARs for those dates and times did not document that the medication was administered. The DON confirmed there was no MAR evidence that the oxycodone had been given. Another resident was cognitively intact, received routine pain medication, and had an order for a fentanyl 50 mcg/hr patch to be applied every 72 hours. Nursing documentation showed the resident had a fentanyl patch on admission, and the MAR reflected patch applications on multiple dates in February 2026. However, the controlled drug count record showed patches were signed out, and there was no documented evidence that an RN and another licensed professional signed for destruction of the old patch after removal on several occasions. The DON confirmed there were not two witness signatures documenting destruction of the fentanyl patches on the listed dates.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper infection control practices were followed during medication administration for one resident. The facility’s medication administration policy dated April 29, 2025 stated that staff were not to touch medications with bare hands. Physician’s orders for the resident included calcium acetate 667 mg three times per day with meals. During observation, an LPN poured the calcium acetate into his bare hand, attempted to pour it into a medicine cup but missed, and the pill landed on the medication cart. He then picked up the pill with his bare hand and administered it to the resident. The LPN stated he should not have touched the pill with his bare hand, and the DON confirmed staff were not to touch residents’ medications with their bare hands. The facility also failed to follow infection control practices during wound care for two residents with multiple wounds. The dressing change policy dated April 29, 2025 indicated that after gloves were removed, hands were to be sanitized to avoid transfer of microorganisms. One resident was cognitively intact, understood and was understood, required assistance with care needs, had multiple wounds including the left ankle, right heel, right posterior thigh and calf, and a pressure ulcer to the sacrum/coccyx area, and was seen weekly by a nurse practitioner from Wound Healing Partners. During wound care, an LPN did not change gloves when moving from dirty to clean areas and did not sanitize hands after doffing gloves and donning new gloves while treating wounds on the left toe, right calf, and coccyx. A second resident was cognitively intact, required assistance with care needs, had a history of multiple venous ulcers, venous insufficiency, and a chronic non-pressure ulcer of the right lower leg. During wound care, the same LPN removed the dirty dressing on the right calf and, without changing gloves, cleaned the area, applied dressing materials, and completed the care. The LPN and DON both confirmed that gloves should have been changed when moving from dirty to clean areas and hands sanitized after glove removal.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that each resident was offered and/or received the pneumococcal immunization for four of 38 residents reviewed. The facility policy dated April 29, 2025 stated that residents would be offered the pneumococcal vaccination if eligible. However, an admission MDS for Resident 2 dated January 26, 2026 showed the resident was cognitively impaired and had not been offered the pneumococcal vaccine, and the immunization record contained no documentation that the vaccine was offered, received, or refused since admission. A quarterly MDS for Resident 16 dated January 14, 2026 indicated the resident was cognitively impaired and was not offered the pneumococcal vaccination, with no immunization record documenting that the vaccine was offered, received, or refused. A quarterly MDS for Resident 36 dated January 19, 2026 also showed the resident was cognitively impaired and was not offered the pneumococcal vaccination, and no immunization documentation was found. An admission MDS for Resident 45 dated February 12, 2026 showed the resident was cognitively impaired and had not been offered the pneumococcal vaccine, and the immunization record contained no documentation that the resident was offered, received, or refused an influenza vaccine since admission. The Infection Preventionist confirmed on February 27, 2026 that Residents 2, 13, 36, and 45 were not offered a pneumococcal vaccine and should have been.

Penalty

No penalty information released

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

Summary

The facility failed to honor one resident’s right to make informed choices and participate in treatment. Resident 71 was cognitively intact, required partial assistance with daily care, and had a diagnosis of diabetes. Physician orders included Mounjaro 2.5 mg subcutaneous once weekly on Wednesday, and the resident later reported asking an LPN during morning medication pass when she would receive her next dose and being told the medication was on hold, with the LPN not knowing why it was held. Resident 71 also stated she was not told that an angiogram was scheduled or that Mounjaro needed to be held for seven days before the procedure. She further stated that bloodwork was drawn and she was not informed of the results. The medical record contained no documented evidence that the resident was informed that Mounjaro was on hold, that the angiogram was scheduled, or that lab results were discussed with her, and the DON confirmed that such documentation was absent and should have been present.

Penalty

No penalty information released

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

Summary

Medication administration was not documented at the time it was given for one resident. During observation on February 25, 2026 at 8:54 a.m., an LPN administered multiple ordered medications to Resident 13, including Amlodipine, Carvedilol, Entresto, Ezetimibe, Gabapentin, Plavix, Calcifediol, Rosuvastatin, Lispro insulin, aspirin, [NAME]-Vite, Pro-stat, sertraline, and preservision. Review of the resident’s MAR later that day showed the medications had not yet been signed off as administered by 12:02 p.m. Resident 13’s quarterly MDS indicated the resident was cognitively impaired, needed staff assistance with daily care tasks, and was diabetic. The facility policy stated medications were to be administered in accordance with physician’s orders and documented at the time of administration, and [NAME] Medication Administration rights stated documentation should occur immediately after the medication is administered. In interview, the LPN stated she does not document medication administration at the time of administration and instead goes back after all medications are passed to document them. The DON stated nurses are expected to document medications as they are administered and not later in the day.

Penalty

No penalty information released

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

Summary

The facility failed to follow physician’s orders related to midline catheter care for 2 residents receiving IV medications and fluids. Resident 3 was cognitively intact, dependent on staff for daily care needs, and receiving IV medications. The physician ordered the midline dressing to be changed every Friday and for arm circumference and external catheter length to be measured. The MAR showed midline dressing changes on February 6, 13, and 20, but there was no documented evidence that arm circumference and external catheter length were measured when the dressing was changed on February 13 and 20. Resident 71 was cognitively intact, required partial assistance with daily care needs, and received IV medications. The physician ordered cefazolin 2 grams IV three times daily for osteomyelitis and ordered the midline to be flushed with normal saline 10 mL prior to and after medication administration twice daily. The MAR showed no documented evidence that the physician was contacted for orders to flush the midline three times a day with normal saline prior to and/or after medication administration, and there was no documented evidence that the midline dressing and securement device were changed every seven days. The DON confirmed that Resident 3’s measurements should have been documented with the dressing changes and that Resident 71’s midline care should have followed the physician’s orders.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that it was free from significant medication errors for one resident who was cognitively impaired, required staff assistance with daily care tasks, and had diabetes. The resident had a physician order to receive 6 units of insulin Lispro with breakfast, and the facility’s meal times showed breakfast was served at 7:15 a.m. During observation of medication administration, the resident received 6 units of Lispro at 8:54 a.m. and did not have any food at that time, meaning the insulin was not administered within five to ten minutes of the meal as required by the manufacturer’s instructions. The Director of Nursing confirmed that the resident had not received the insulin per the manufacturer’s instructions.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the implementation of a resident-centered care plan related to nutritional interventions for Resident 2. A comprehensive MDS assessment dated September 4, 2025 documented that the resident was cognitively impaired and dependent on staff for daily care tasks, including feeding, and had increased nutrition risk due to requiring staff assistance and having swallowing difficulties. The resident’s care plan, last updated on the same date, specified that an alternative meal was to be offered whenever the resident consumed less than fifty percent of a meal. Review of the resident’s November 2025 meal intake records showed multiple instances where the resident ate less than fifty percent of meals across breakfasts, lunches, and dinners on numerous dates throughout the month. There was no documented evidence that an alternative meal was offered on any of these occasions, despite the care plan requirement. In an interview on February 12, 2026 at 2:14 p.m., the Director of Nursing confirmed there was no indication that the resident had been offered an alternative meal on those dates and acknowledged that the resident should have been offered one according to the care-planned intervention.

Penalty

No penalty information released

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

Summary

The facility failed to initiate nutritional interventions and ensure sufficient food and fluid intake for a cognitively impaired resident who was dependent on staff for feeding. A comprehensive MDS assessment dated September 4, 2025, showed that the resident had swallowing difficulties and required staff assistance with all daily care tasks, including feeding. The resident’s care plan, updated the same day, identified increased nutrition risk and directed staff to offer an alternative meal if the resident consumed less than 50% of a meal and to spoon feed nectar thick liquids. Meal intake records for November 2025 documented that the resident ate less than 50% of multiple meals across numerous days, including several breakfasts, lunches, and dinners. Despite these repeated low intakes, there was no documented evidence that staff offered alternative meals or additional fluids for hydration on the identified dates, as required by the care plan. On November 23, 2025, a nursing note recorded that the resident’s sister expressed concern about the resident’s recent poor intake and lethargy. Later that day, another nursing note documented that the resident was found unresponsive and in respiratory distress and was transferred to the hospital. A subsequent nursing note indicated that the resident was admitted with hyponatremia, a urinary tract infection, and pneumonia. In an interview, the DON confirmed there was no indication that the resident had been offered alternative meals or fluids on the dates of poor intake and acknowledged that this should have occurred.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the confidentiality of a resident's personal health information during a lunch service. The Health Insurance Service Coordinator discussed private medical information, including guardianship, insurance plan, and dialysis details, with the resident at her dining table in the presence of other residents, a family member, and multiple staff members. The conversation took place in a public area where others could overhear, rather than in a private setting as required by facility policy. The resident involved was cognitively intact and able to communicate effectively. She later expressed discomfort with having her personal information discussed openly and stated she would have preferred a private conversation. Both the Health Insurance Service Coordinator and the Nursing Home Administrator acknowledged that the discussion should have been conducted in a private area, in accordance with the facility's policy on protecting resident health information.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen, one second-floor pantry, and one third-floor pantry refrigerator. In the main walk-in freezer, surveyors observed 25 egg omelets, 15 sausage patties, five chicken cutlets, six pork chops, and about one-third of a bag of frozen carrots that were not dated with an opened date and were open to the air. The same freezer also had an approximate three-foot by one-and-one-half-foot buildup of ice on the back wall that extended from a pipe below the ceiling into and through the lid of a cardboard box containing bags of frozen perogies. In the second-floor pantry, surveyors observed three boxes of frozen waffles that were undated and open to the air, and a box containing one and one-half pieces of pizza that was not dated or labeled with a resident name. In the third-floor pantry refrigerator, there was a moderate amount of orange-colored dried sticky substance on the lower bottom right storage drawer. In the kitchen, washed and ready-to-use insulated serving bowls, plastic measuring cups, and a large plastic pitcher had moderate to large amounts of removable dried food substance inside them, and a five-pound bag of dried noodles on a prep table shelf was labeled and dated but open to the air. During lunch service, [NAME] 2 plated a cold meal and a hot substitute meal, but the food temperature log did not show that the hot food items were temperature-checked before plating. The Regional Dietician confirmed the hot foods were not temped prior to plating, and the Nursing Home Administrator confirmed that food in the kitchen and pantry should be labeled, dated, not open to the air, and that dinnerware, freezers, refrigerators, and food should be sanitary and properly temperature-checked before serving.

Penalty

No penalty information released

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

Summary

The facility failed to complete accurate MDS assessments for four residents by not coding required items based on documented care and medication use. For Resident 3, physician orders included oxygen as needed to keep oxygen saturation above 90%, and the MAR showed oxygen was administered within the 14-day lookback period, but the quarterly MDS did not code Section O0110C1 to reflect oxygen therapy. The RNAC later confirmed that the assessment was coded incorrectly and should have indicated oxygen therapy during the lookback period. For Resident 45, the admission MDS did not code Section N0415E for anticoagulant use even though the physician ordered Enoxaparin daily and the MAR showed it was administered during the seven-day lookback period. For Resident 8, the comprehensive MDS indicated the resident was to be interviewed for mental status in Section C0100, but Sections C0200 through C0500 were coded not assessed. For Resident 82, the physician ordered daily oxycodone for severe headaches and the MAR showed daily administration during the assessment period, but the quarterly MDS did not code Section N0415H to show opioid use. The RNAC confirmed that the MDS assessments for Residents 45, 8, and 82 were not coded correctly.

Penalty

No penalty information released

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

Summary

The facility’s QAPI committee failed to maintain compliance with nursing home regulations and did not ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Survey findings from multiple prior surveys and the current survey showed repeated deficiencies involving inaccurate MDS assessments, care plan timing and revision, accountability of controlled medications, monthly pharmacy reviews, proper storage of medications, and food procurement, storage, preparation, and serving under sanitary conditions. The facility’s prior plans of correction for deficiencies cited on earlier surveys stated that audits would be completed and the results reported to the QAPI committee for review. Despite those plans, the current survey found that the QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments, care plan timing and revision, controlled medication accountability, monthly pharmacy reviews, labeling and storing drugs and biologicals, and sanitary food handling. The report also notes repeated deficiencies across surveys ending August 22, 2024, December 23, 2024, April 22, 2025, and September 11, 2025.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that comprehensive admission MDS assessments were completed within the required time frame for four of 50 residents reviewed. The RAI User's Manual dated October 2023 stated that an admission MDS assessment must be completed no later than 14 days after admission, but the records showed that the admission MDS assessments for Residents 35, 45, and 89 were each completed 14 days after admission, and the assessment for Resident 117 was completed 16 days after admission. Clinical record review showed that Resident 35's comprehensive admission MDS was dated July 8, 2025 and completed July 15, 2025; Resident 45's was dated August 27, 2025 and completed September 3, 2025; Resident 89's was dated August 25, 2025 and completed September 3, 2025; and Resident 117's was dated May 21, 2025 and completed June 2, 2025. During an interview on September 11, 2025, at 12:08 p.m., the Nursing Home Administrator confirmed that these admission MDS assessments were not completed within the required time frames.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the care plans for two residents were updated and revised to reflect their current care needs. The facility policy stated that each resident should have a comprehensive person-centered care plan that is reviewed on an ongoing basis and revised as indicated by the resident’s needs, wishes, or a change in condition, including at least with each comprehensive and quarterly assessment. Review of the clinical record for one resident showed a quarterly MDS assessment identifying cognitive intactness, assistance needs, five venous ulcers, a diabetic foot ulcer, an unstageable pressure ulcer not present on admission, and diagnoses of chronic venous hypertension and diabetes. Although the care plan included a pressure redistribution mattress, it did not reflect a physician’s order for a 42-inch concord mattress with bolster overlay and gap filler that had been added to the resident’s bed. Review of the second resident’s record showed a quarterly MDS assessment identifying cognitive intactness, supervision needs with care and ambulation, independent wheelchair mobility, frequent bowel and bladder incontinence, no diuretic use, and a diagnosis of hypertension. The resident’s care plan still included interventions for monitoring adverse reactions to diuretic therapy and holding medications for SBP less than 100 mmHg and/or HR less than 60 bpm, even though the MAR and physician’s orders showed no diuretic medication and no active order for those holding parameters. The DON confirmed that the care plan had not been revised to reflect that the resident was no longer on a diuretic and that the heart rate holding parameters had been discontinued.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a complete and accurate accounting of controlled medications for two residents. For one resident with dementia and heart failure who required staff assistance with daily care needs, physician orders included oxycodone 10 mg orally every 4 hours for pain. The controlled drug record showed multiple sign-outs of oxycodone in June, July, and August 2025, but the MAR contained no documented evidence that the medication was administered on those dates. The DON confirmed there was no documented evidence that the resident received the ordered oxycodone on the referenced dates. For another resident who was cognitively intact and received routine pain medications, physician orders included oxycodone 5 ml every 6 hours as needed for severe pain. Review of the controlled drug accountability records for July, August, and September 2025 showed multiple doses signed out for administration, but there was no documented evidence that the signed-out doses were actually administered. The DON confirmed that there was no documented evidence that the oxycodone doses were administered to the resident on the dates and times listed.

Penalty

No penalty information released

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

Summary

The facility failed to respond to a pharmacy recommendation for one resident reviewed. Facility policy dated April 29, 2025 stated that the consultant pharmacist would conduct medication regimen reviews, make recommendations based on information available in the resident's health record, and provide the MRRs to designated facility personnel for distribution to the attending physician, medical director, and other necessary staff. The policy also stated that copies of the consultant pharmacist's reports should be maintained in the facility and in the resident's permanent health record. For the resident involved, a quarterly MDS assessment dated June 25, 2025 showed the resident was cognitively intact, required supervision with care needs and ambulation, was independent with wheelchair mobility, received insulin, antianxiety medications, antidepressant medications, and opioid medications, and had diagnoses of hypertension and MS. A pharmacy medication regimen note dated April 7, 2025 indicated irregularities/recommendations were noted, but there was no documented evidence in the clinical record of the recommendations or that they were addressed by the physician. The DON stated on September 10, 2025 that she was unable to find the pharmacy recommendations and confirmed the recommendation was not addressed by the physician.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications were properly stored for one resident who was cognitively intact and required staff assistance with daily care needs. The resident’s quarterly MDS, dated August 21, 2025, documented diagnoses including diabetes, depression, high blood pressure, and deep vein thrombosis, and noted use of an antipsychotic, antidepressant, anticoagulant, diuretic, and hypoglycemic medication. During an observation on September 8, 2025, at 9:13 a.m., the resident was lying in bed with an unsupervised medicine cup containing 10 unlabeled clean and dry pills on the overbed table, and an unlabeled medication cut in half on the bedside table. When interviewed at that time, the resident stated the pills were her morning medications that the nurse had left for her to take. An LPN later stated the resident was permitted to take her medications on her own and needed to take them with food, but there was no documented evidence in the clinical record that the resident had been assessed for self-administration of medications. The LPN also stated she had been told during training that the resident took her own medications, then confirmed that this was not correct and that such permission would be noted in physician orders. The DON confirmed that the resident’s medications should not have been left unsupervised and unlabeled at the bedside.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that physician's orders regarding medication administration for two residents with end-stage renal disease (ESRD) receiving hemodialysis were properly clarified. Both residents had physician's orders indicating that medications could be administered either prior to dialysis or upon return from dialysis, but there was no documented evidence that the facility contacted the residents' physicians to clarify which specific medications should be given at each time. This lack of clarification was identified through review of clinical records, the Pennsylvania Nurse Practice Act, and staff interviews. One resident was noted to be cognitively intact and required staff assistance for daily care, while the other was able to understand and be understood by others. Both residents had scheduled dialysis sessions multiple times per week. Despite the presence of multiple, potentially conflicting orders regarding medication timing on dialysis days, the facility did not document any communication with the physicians to resolve these ambiguities. The Director of Nursing confirmed that no such clarification was obtained or documented for either resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by not following physician's orders for medication administration and therapy evaluations. For one resident with end-stage renal disease (ESRD) receiving hemodialysis, there was no documented evidence that multiple prescribed medications, including antihypertensives, antidepressants, blood thinners, and dietary supplements, were administered as ordered either prior to or after dialysis sessions on numerous specified dates. The care plan and physician's orders clearly indicated the need for medication administration in relation to dialysis, but the Medication Administration Records did not reflect that these orders were followed. Another resident, also with ESRD and Parkinson's disease, had similar deficiencies in medication administration. The records showed that several doses of prescribed medications, including midodrine, methocarbamol, and carbidopa-levodopa, were not documented as given before or after dialysis on multiple occasions. The care plan for this resident also specified the importance of medication timing in relation to dialysis, but staff failed to document administration as required. The DON confirmed that there was no evidence these medications were given as ordered and acknowledged that the timing of doses was not clarified with the physician when concerns arose. Additionally, the facility did not follow through on a therapy screening ordered for one resident after an orthopedic consult. Although the order for a therapy screen was present in the clinical record, and the resident had previously received therapy services, the required screening was not completed. The Director of Rehabilitation and the DON both confirmed that the therapy screen was not conducted as ordered.

Penalty

No penalty information released

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

Summary

The facility failed to follow its own policy regarding the care and monitoring of residents receiving dialysis. According to the facility's Hemodialysis Care policy, staff are required to conduct and document a pre-dialysis assessment using a dialysis communication tool, print it, and send it with the resident to the dialysis center. After dialysis, staff are expected to receive a report from the dialysis provider and/or review the documentation provided, and promptly contact the dialysis center with any questions or concerns. For one resident with end-stage renal disease who was cognitively intact and required assistance with daily care, there was no evidence in the clinical record or at the nursing station that these assessments or communications were being completed or shared as required. An interview with the DON confirmed that there was no documented evidence of pre-dialysis assessments being sent with the resident or of post-dialysis information being received and reviewed by staff, as outlined in the facility's policy. This deficiency was identified through review of policies, clinical records, observations, and staff interviews.

Penalty

No penalty information released

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

Summary

The facility failed to serve food items that were palatable, as required by its own policy. During observation of the lunch meal tray line, dietary staff prepared and delivered trays to residents on the second floor low hall. A test tray revealed that the milk was 45.4°F and tasted cold, orange juice was 51.4°F, coffee was 142°F, beef stew was 117°F and tasted cold and not palatable, and cauliflower was 129°F, unseasoned, tasted cold, overcooked, and not palatable. The Dietary Manager confirmed that the beef stew was cold and not palatable, and the cauliflower was mushy and lacked seasoning. These findings were based on direct observation, temperature measurements, and staff interviews.

Penalty

No penalty information released

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

Summary

A cognitively intact resident with end stage kidney failure and a diagnosis of neurogenic bladder was admitted to the facility and required straight catheterization three times daily, as ordered by a physician. The resident also received dialysis three times per week. The care plan and physician's orders specified the need for straight catheterization every shift, regardless of the resident's dialysis schedule. Review of the medication and treatment administration records for July and August revealed multiple instances where the resident did not receive straight catheterization as ordered, particularly on days when the resident was scheduled for dialysis, despite not leaving for dialysis until later in the morning. Additional documentation indicated missed catheterizations on other dates and shifts, with reasons such as the resident not being available or the procedure being completed on a previous shift. The DON confirmed that there was no documented evidence that the straight catheterization was completed as ordered on the identified dates and shifts.

Penalty

No penalty information released

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

Summary

The facility failed to provide scheduled showers and document bathing care for four residents who required assistance with activities of daily living, specifically bathing and hygiene. Facility policy required that residents be bathed or showered according to their preferences at least twice per week, with refusals to be reported and documented. However, for multiple residents, there was no documented evidence that their bathing preferences were obtained or followed, and no record of showers or refusals as required by policy. One resident, who was cognitively intact and required assistance with bathing and toileting hygiene, reported receiving only one shower during a two-week stay, with no documentation of bathing preferences or scheduled showers in the clinical record. Another resident, also cognitively intact and with frequent incontinence, had physician orders and a care plan specifying showers on certain days, but there was no documentation that these showers were provided or refused, nor that bed baths were offered as an alternative. Two additional residents, one cognitively impaired and the other cognitively intact, both had physician orders and care plans specifying regular showers and documentation of refusals. For both, there was no evidence in the records that showers were provided as ordered, nor that refusals or alternative care were documented. The DON confirmed the lack of documentation for all four residents, indicating a failure to provide and record necessary bathing care as per facility policy and physician orders.

Plan Of Correction

Residents # 4, 5, 6, and 7 have had no adverse effects from not being showered according to preference. Residents 4, 5, 6, and 7 were showered according to preference as care planned. To identify residents who have the potential to be affected, the Director of Nursing/designee will complete an audit of shower preferences and ensure care plans are accurate. To prevent recurrence, the licensed nursing staff and nurse aides will be educated on the facility Resident bathing/showering/scheduling policy by the Director of Nursing/designee. To maintain and monitor compliance, audits of 6 residents to ensure showers are completed according to preference audits will be completed weekly x 4 and monthly x 2.

Penalty

No penalty information released

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

Summary

The facility failed to serve food items that were palatable, as required by its policy on food temperatures. During observation of the supper meal service, it was noted that there was a significant delay between the preparation of the food cart and the actual serving of the trays to residents. A test tray revealed that while cold items such as milk and salsa salad were served at appropriate cold temperatures, hot food items including taco beef and rice were served at temperatures of 109.3°F and 113.2°F, respectively, and were described as cold and not palatable. The Dietary Manager confirmed that these hot food items were indeed cold and not palatable at the time of service.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food service safety by not ensuring that dietary staff wore appropriate hair restraints during food preparation and tray line service. The facility's policy, dated February 14, 2025, mandates that staff in Food and Nutrition Services must wear clean and appropriate hairnets and hair restraints that cover all hair, including beards and facial hair. However, observations in the main kitchen on April 22, 2025, revealed that Dietary Staff 2 was plating breakfast meals without a facial hair restraint. During an interview, Dietary Staff 2 admitted to removing the restraint because it was hot and he had to answer the phone multiple times. Further observations on the same day at lunchtime showed that Dietary Aide 3 was pushing carts in the main kitchen without a hair restraint. Upon interview, Dietary Aide 3 confirmed that she should have been wearing a hair restraint, but it must have fallen off when she went outside. The Interim Certified Dietary Director confirmed that the dietary department was fully staffed on April 21, 2025, and that staff should have had their hair covered appropriately with hair restraints.

Plan Of Correction

Dietary staff adorned appropriate hair restraints during food preparation and tray line service. Certified Dietary Manager and/or designee will educate dietary staff on Dress and Personal Hygiene and Employee Sanitary Practices Policies. Dietary Manager and/or supervisor will monitor compliance daily with kitchen observation. Administrator and/or designee will perform random audits to verify staff are wearing appropriate hair restraints during food preparation and tray line service. These audits will be completed 3 times weekly for two weeks and 1 time weekly for four weeks. The results of these audits will be reviewed by the Quality Assurance Performance Improvement team for further recommendations.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to physician's orders for a resident, identified as Resident 2, regarding the application of barrier cream. According to the resident's care plan and physician's orders, the Triad barrier cream was to be applied every shift and after each episode of incontinence. However, interviews and clinical record reviews revealed that the cream was only applied every shift and not after each incontinent episode as required. This was confirmed by both the resident and a Licensed Practical Nurse (LPN), who acknowledged the deviation from the prescribed care plan. Further examination of Resident 2's clinical records showed multiple instances where there was no documented evidence of the cream being applied as ordered. Specific dates were noted where the application was missed on various shifts throughout March 2025. An interview with the Director of Nursing (DON) corroborated the findings that the barrier cream was not applied according to the physician's orders, leading to a deficiency in the quality of care provided to the resident.

Plan Of Correction

Resident #2 has had no adverse effects from moisture barrier not being documented. Current skin preventative creams and treatments will be reviewed with the physician or NP to determine necessary measures, and orders implemented as received. To identify residents who have the potential to be affected, the Director of nursing/ designee will complete a review of residents who are incontinent and receive moisture barrier to determine if any administrations missed. If missed administrations identified, a skin check will be conducted. To prevent recurrence, the licensed nursing staff will be educated on the physician/ provider orders policy including carrying out orders by the Director of nursing/ designee. To maintain and monitor compliance, audits of 5 residents receiving moisture barrier will be conducted by the Director of nursing/ designee to ensure residents receive it as ordered weekly x 4 weeks and monthly x 2.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that clinical records were complete and accurately documented for one of the residents reviewed. Specifically, a quarterly Minimum Data Set (MDS) assessment for the resident indicated that the resident was sometimes understood and able to sometimes understand others, and was dependent on staff for personal hygiene care. However, discrepancies were found in the nursing notes related to the resident's care. A nursing note dated April 2, 2025, incorrectly documented that a straight catheterization was attempted three times without success. An interview with the Director of Nursing later revealed that this procedure was not attempted on the resident, and the note was mistakenly placed in the wrong chart. This error highlights a failure in maintaining accurate and complete clinical records for the resident, as required by regulatory standards.

Plan Of Correction

Resident #2 medical recorded updated marked progress note as invalid for incorrect documentation. To identify residents who have the potential to be affected, the Director Nursing/Designee will complete a review of nursing progress notes for the past 30 days to ensure that documentation is correct and accurate. To prevent recurrence, the licensed nursing staff will be educated on accurate and timely documentation of the medical record. To maintain and monitor compliance, the Director of Nursing/ designee will review progress notes of 5 residents weekly x's 4 weeks and monthly x's 2. Step 4: To maintain and monitor compliance, the Director of Nursing/ designee will review progress notes of 5 residents weekly x's 4 weeks and monthly x's 2.

Penalty

No penalty information released

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

Summary

The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the necessary number of NAs per residents during various shifts over a six-day period from March 25 to March 30, 2025. On five of these days, the day shift was understaffed, with the number of NAs falling short of the required ratio. Additionally, the evening shift was understaffed on one day, and the night shift was understaffed on four days. The facility's census data and nursing time schedules were reviewed, revealing discrepancies between the required and actual staffing levels. The facility census varied from 93 to 98 residents during the reviewed period, necessitating specific numbers of NAs per shift to comply with the regulation. However, the actual staffing levels consistently fell short, with the most significant deficiencies noted on the day and night shifts. Interviews with the Nursing Home Administrator confirmed the facility's failure to meet the staffing requirements, and there were no additional higher-level staff available to compensate for these deficiencies.

Plan Of Correction

1. Facility unable to correct nurse aide staffing hours for the cited 5 of 6 days on day shift, 1 of 6 days for evening shift, and 4 of 6 days for night shift. 2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy. 3. The Administrator or designee will audit the direct care staffing five times per week to ensure regulatory compliance. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical, management staff will consider delaying, limiting new admissions, or placing admissions on hold. 4. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.

Penalty

No penalty information released

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

Summary

The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on three out of six days reviewed. Specifically, the facility provided only 3.07 hours on March 25, 3.15 hours on March 29, and 2.87 hours on March 30, 2025. This deficiency was identified through a review of nursing time schedules and confirmed during an interview with the Director of Nursing on April 1, 2025, who acknowledged the shortfall in meeting the required care hours on the specified days.

Plan Of Correction

1. Facility unable to correct the staffing hours on the cited dates; efforts are continuously being made to maintain the staffing hours within regulatory guidelines. 2. To help prevent reoccurrence, the Director of Nursing or Designee will in-service the scheduling staff on the importance of staffing the facility according to the regulation and policy. 3. The Administrator or designee will audit direct care staffing hours five times per week to ensure regulatory compliance. The facility will continue with recruiting efforts, as well as offering employment incentives in order to increase staff availability. When there are staffing challenges, administrative staff can/will assist with mealtime, answering call bells, etc. When there is a call off, the scheduler makes contact with all staff via phone/text to find coverage. We encourage staff to take turns in staying beyond their regularly scheduled shift to cover call offs. Agency personnel are utilized as necessary to assist in staffing regulatory compliance. Facility staff can volunteer to pick up open shifts. When staffing is critical, management staff will consider delaying, limiting new admissions, or placing admissions on hold. 4. The audit outcomes will be presented to the Quality Assurance committee for review and recommendations.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary services to maintain personal hygiene for a dependent resident, identified as Resident 2, who was cognitively impaired and required extensive assistance for daily care needs, including bathing. According to the resident's care plan, they preferred showers on Sundays and Wednesdays during the second shift. However, a review of the resident's bathing records for January, February, and March 2025 showed that the resident did not receive any showers during these months. There was no documentation indicating that the resident was offered a shower and refused it during this period. An interview with the Director of Nursing confirmed that the resident was not showered in these months, and there was no evidence of refusal.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely treatment for a newly identified pressure ulcer in a resident. The resident, who was cognitively intact and required substantial assistance with bed mobility, was at risk for developing pressure ulcers and was incontinent of urine and frequently incontinent of bowel. On December 28, 2024, a registered nurse was notified of a new pressure ulcer on the resident's coccyx, measuring 0.5 x 1.0 x 2.0 cm with tunneling. A foam dressing was applied, and the physician and resident representative were notified. However, there was no documented evidence of a physician's order for treatment until December 31, 2024, and the treatment was scheduled to start on January 1, 2025. By January 3, 2025, the wound had worsened to a Stage 3 pressure ulcer, measuring 1.5 x 1.3 x 1.0 cm with moderate serosanguineous drainage. The Director of Nursing confirmed that the physician was notified of the new pressure ulcer, but a treatment order was not obtained at the time of notification, which should have been done. This delay in obtaining a treatment order and starting the appropriate care contributed to the worsening of the resident's pressure ulcer.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate respiratory care for a resident, as evidenced by the incorrect administration of oxygen. The resident, who was admitted with acute respiratory failure and hypoxia, had a physician's order for continuous oxygen at a flow rate of 4 liters per minute (LPM) via nasal cannula. However, during a visit by the resident's daughter, it was discovered that the oxygen was set at 3 LPM, which was below the prescribed rate. This discrepancy was confirmed by a nursing note dated January 19, 2025, and an interview with the Director of Nursing. Upon assessment, the resident's oxygen saturation was critically low at 68 percent on the incorrect flow rate. The nurse increased the oxygen flow to 5 LPM, which only marginally improved the saturation to 77 percent. Subsequently, the resident was placed on a non-rebreather mask, which increased the oxygen saturation to 93 percent, but the resident's mental status remained unchanged. The physician was notified, and the resident was sent to the hospital, where he was admitted with pneumonia, hypoxia, and a non-ST-elevation myocardial infarction.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the unavailability of a prescribed inhaler for several days. The resident, who was cognitively intact and had chronic obstructive pulmonary disease (COPD) and asthma, was supposed to receive fluticasone propionate inhaler twice daily. However, the medication was not administered on multiple occasions in January 2025 due to it being unavailable in the Omnicell or awaiting delivery from the pharmacy. Interviews and documentation revealed that the nursing staff was aware of the medication's unavailability but failed to ensure timely delivery or administration. The Director of Nursing confirmed the lack of documentation for the medication's administration and was unaware of the reasons for the delivery issues. The resident expressed confusion and concern over the repeated unavailability of her medication, highlighting a significant lapse in the facility's medication management processes.

Penalty

No penalty information released

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

Summary

The facility failed to update and revise the care plans for two residents to reflect their specific care needs. For Resident 2, who was cognitively impaired and had a history of falls, the care plan was not updated after an unwitnessed fall. Although interventions were made, such as discontinuing the air mattress and marking the appropriate mattress height with a decal, these changes were not documented in the care plan. The Director of Nursing confirmed that the care plan did not reflect the intervention for the decal to ensure the mattress was kept at the appropriate level. Similarly, Resident 5, who was also cognitively impaired and had a history of falls, was observed in a low bed with bilateral fall mats, but these interventions were not documented in the care plan. The Assistant Director of Nursing confirmed that the care plan was not revised to include the need for a low bed and fall mats. These omissions indicate a failure to ensure that the care plans were updated to reflect the residents' specific care needs, as required by the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure safe transfer techniques were used in accordance with the care plan for a resident, resulting in a fall. The resident, who was cognitively impaired and dependent on assistance for transfers, was supposed to be transferred with moderate assistance from two staff members using an orbiturn. However, during a transfer, the resident slid off the chair and fell to the floor, sustaining bruising and discomfort. The incident occurred because a nurse aide transferred the resident with the help of a private caregiver instead of another facility staff member, as required by the care plan. The resident had a history of hemiparesis and required specific support during transfers, as outlined in their care plan. Despite the care plan's clear instructions, the nurse aide did not adhere to the requirement of using two facility staff members for the transfer. The Director of Nursing confirmed that the nurse aide's actions did not align with the care plan, as the aide used a private caregiver instead of another staff member. This deviation from the care plan led to the resident's fall and subsequent injuries.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to follow a physician's recommendations for a resident with a Stage IV pressure ulcer, resulting in the deterioration of the wound. The resident was admitted with a Stage IV pressure ulcer and was recommended to have a high protein diet, a low air loss mattress, frequent repositioning, and a wound vacuum. However, the facility did not document evidence of ordering or applying the wound vacuum, nor did they schedule a follow-up appointment as recommended. The resident's wound showed stalled healing and increased in size, with no evidence of the recommended treatments being followed. Additionally, the facility did not document weekly skin checks for another resident, as ordered by the physician. The resident required maximum assistance and was cognitively intact, but there was no evidence in the clinical record that skin checks were completed for two months. This lack of documentation was confirmed by the Assistant Director of Nursing. Furthermore, the facility failed to document urinary output for a resident with a Foley catheter, as required by a physician's order. The resident was cognitively intact and required maximum assistance, but there was no documented evidence of urine output being recorded each shift over several months. This deficiency was confirmed by the Director of Nursing.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to provide necessary treatment and services for a Stage 4 pressure ulcer for Resident 13, resulting in the deterioration of the wound. Upon admission, Resident 13 had a Stage 4 pressure ulcer with exposed bone on the sacral area. A wound healing consult recommended a high protein diet, a low air loss mattress, frequent repositioning, and a wound vacuum, among other treatments. However, the physician's orders only included a Dakins wet-dry dressing, and there was no evidence that a wound vacuum was ordered or applied. Additionally, the resident did not receive the recommended follow-up appointment at the wound clinic due to scheduling conflicts, and the wound was not assessed by a registered nurse or the wound team since July 23, 2024. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the facility failed to obtain a wound vacuum, ensure follow-up wound appointments, and make additional referrals to the wound clinic. As a result, Resident 13's wound declined, with measurements indicating an increase in size and depth. The resident expressed discomfort and pain, particularly when sitting in a chair at dialysis, as she was unable to offload pressure or reposition. The facility's inaction and failure to follow through with recommended treatments and assessments contributed to the deterioration of the resident's condition.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to ensure that residents and/or their representatives were given the opportunity to develop advance directives, as required by their policy. This deficiency was identified for 12 out of 45 residents reviewed. The facility's policy, dated July 1, 2024, mandates that upon admission, residents should meet with a healthcare team member to discuss and document their preferences for advance care planning, including living wills and medical power of attorney. However, the review of clinical records for the affected residents showed no documented evidence that these discussions took place or that residents were informed of their rights to develop advance directives. The residents involved had varying levels of cognitive function, with some being cognitively intact and others impaired. Despite these differences, there was no documentation indicating that any of the residents or their representatives were provided with the necessary information or assistance to formulate advance directives. The Social Service Director confirmed the lack of documentation, indicating a systemic failure to address advance directives with residents and their representatives throughout their stay, as required by the facility's policy and resident rights regulations.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to serve hot foods at the proper and palatable temperatures as required by their policy. The policy, dated June 1, 2024, mandates that hot foods should be served at 135 degrees Fahrenheit or above. During an observation of the lunch meal tray line in the main kitchen on August 21, 2024, it was noted that the food cart for the Second Floor left the kitchen at 12:28 p.m. and arrived at 12:32 p.m. The last resident was served at 12:43 p.m., and at 12:45 p.m., the temperature of the chicken breast was recorded at 124 degrees Fahrenheit, which was lukewarm and not appetizing. An interview with the Dietary Director confirmed that the hot foods should have been served at 135 degrees Fahrenheit. This deficiency was identified under the regulation 28 Pa. Code 211.6(b) Dietary Services.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations and staff interviews. The kitchen and its equipment were found to be unclean, with a microwave covered in a white, creamy substance, and a meat slicer and mixer with dried food remnants. Additionally, the ice cream freezer lacked a thermometer, and there was general debris under the coffee counter and throughout the kitchen. Food items in the kitchen and pantries were not properly labeled, dated, or secured, with several items found opened and exposed to air. In the walk-in cooler, various food items, including muffins, ham slices, and cheese, were undated and exposed to air. Similarly, in the walk-in freezer and second-floor pantry freezer, several items were found opened, undated, and unlabeled. The facility also failed to ensure proper hygiene practices among staff during food preparation. Observations during the tray line revealed that several dietary staff members wore hairnets that did not fully cover their hair, with hair tendrils exposed on their necks and foreheads. Additionally, a 10-pound ham was observed thawing improperly on the prep area counter, and there was a puddle of water under the ice machine extending onto the kitchen floor. An interview with the Dietary Manager confirmed that these issues should not have occurred and that staff were expected to have their hair completely covered.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and gnats in the kitchen's food prep area. Observations on August 19, 2024, revealed approximately six flies and several gnats around the sink and general kitchen area. The facility's pest control policy, dated July 1, 2024, stated that treatment would be rendered as required to control insects, but the presence of pests indicated a lapse in this policy. Interviews with the Dietary Manager and Maintenance Director revealed that the pest control company was visiting every other month, with the last visit on June 20, 2024. Despite these visits, the pest issue persisted. The Maintenance Director requested an additional visit from the pest control company on August 19, 2024, after being informed of the problem. The pest control company recommended thorough cleaning, eliminating food debris, proper ventilation, and installing fly lights. The Nursing Home Administrator confirmed that flies and gnats should not be present in the kitchen.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to ensure that residents and/or their responsible parties were given the opportunity to participate in the development and implementation of person-centered care plans. This deficiency was identified for two residents during a review of policies, clinical records, and staff interviews. The facility's policy, dated July 1, 2024, mandates that residents and their representatives should be involved in discussing care goals, including preferences for advanced care planning, and that these discussions should be documented. However, for Resident 12, who was cognitively impaired but able to understand and communicate, there was no evidence of a care plan conference being scheduled or completed after the Minimum Data Set (MDS) assessment. An interview with the Registered Social Worker confirmed that a meeting was initially scheduled but was rescheduled and eventually not held, with no subsequent meetings scheduled. Similarly, for Resident 77, who was cognitively intact and required assistance with care needs, there was no documented evidence of a care plan conference following the MDS assessment. An interview with the Registered Nurse Assessment Coordinator confirmed the absence of a scheduled or completed care plan conference and the lack of notifications or invitations to the resident or their representative. The Director of Nursing confirmed that care conferences should occur quarterly, indicating a failure to adhere to this schedule for both residents.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to obtain physician's orders for pacemaker checks for a resident, as required by both the Pennsylvania Nursing Practice Act and the facility's own policy. The resident, who was cognitively impaired and had a cardiac pacemaker, was admitted to the facility with a care plan indicating the need for pacemaker checks per physician's order. However, there was no documented evidence in the resident's clinical record of any physician's order for these checks, nor any documentation that the checks had been completed since the resident's admission. Interviews with the Nursing Home Administrator and the Registered Nurse Assessment Coordinator confirmed the absence of documented evidence for the pacemaker checks. The RNAC also noted that the resident had missed a scheduled pacer clinic appointment. This oversight indicates a failure to adhere to the facility's policy and the resident's care plan, which required routine pacemaker checks to ensure the device's proper functioning.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to follow physician's orders and residents' requests for ophthalmology appointments for two residents. Resident 69, who was cognitively intact and required supervision with care needs, expressed a desire to see an eye doctor due to severe vision impairment. Despite a scheduled appointment, a miscommunication with Senior Life and transportation issues prevented the visit. The Social Service Director received an email from the local Senior Services office about the need to reschedule the vision exam, but no further attempts were documented to follow up or reschedule the appointment after the initial email. Resident 87, who was cognitively impaired and had a diagnosis of diabetes, was ordered by a physician to have a vision exam with 360 services. An email was sent by a registered nurse to the Social Service Director to schedule this exam, but there was no documented evidence in the resident's clinical record that the appointment was ever scheduled. The Nursing Home Administrator confirmed the lack of documentation for the scheduling of the vision exam for Resident 87.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to respond in a timely manner to pharmacy recommendations for two residents, leading to a deficiency in medication regimen review. For Resident 30, who was cognitively impaired and required total care, a pharmacy consultant recommended reassessing the prescription for midodrine to avoid administration after 6:00 p.m. However, the medication was scheduled for 8:00 p.m., and there was no documented evidence that the physician addressed this recommendation by August 22, 2024. This was confirmed by the Director of Nursing during an interview. Similarly, for Resident 89, who was cognitively intact and dependent on staff for daily care, the pharmacist recommended reviewing the concurrent use of Citalopram and Cilostazol and stopping the order for nystatin. Additionally, a lipid panel was recommended. There was no documented evidence that these recommendations were addressed by the physician, as confirmed by the Assistant Director of Nursing. These failures to act on pharmacy recommendations were in violation of the facility's policy and state regulations.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the lack of documented non-pharmacological interventions prior to administering such medications. The facility's policy required that all residents receiving psychoactive medications have their behaviors and the effectiveness of interventions monitored and documented. However, for one resident, there was no evidence that non-pharmacological interventions were attempted before administering Ativan and Xanax on multiple occasions. The resident in question was cognitively impaired with diagnoses including Alzheimer's disease, dementia with agitation, and anxiety. Despite physician orders for medication monitoring and documentation of non-pharmacological interventions, the Medication Administration Record showed repeated administration of Ativan and Xanax without prior attempts at non-pharmacological interventions. This was confirmed by the Registered Nurse Assessment Coordinator, who acknowledged that such interventions should have been attempted before administering the medications.

Penalty

Inspection fine: $76,811

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in handling soiled linens and personal protective equipment (PPE) for a COVID-19 positive resident. The facility's policy required soiled linens to be bagged at the point of use and placed in a designated soiled linen bin. However, observations revealed that a nurse aide carried dirty linens from a droplet isolation room to a linen cart in the hallway without bagging them, which was confirmed by the aide and the Nursing Home Administrator. Additionally, Resident 11, who was COVID-19 positive, was on droplet precautions, but the signage incorrectly indicated contact precautions, and there was no appropriate receptacle for disposing of used PPE in the resident's room. The Director of Nursing confirmed that the correct transmission-based precaution signs should have been posted, and appropriate receptacles for soiled PPE should have been available. The facility's failure to provide a dirty linen bin in each isolation room and the incorrect handling of contaminated PPE and linens contributed to the deficiency. The report highlights the facility's non-compliance with infection control protocols, as outlined in the relevant Pennsylvania Code sections.