Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quality Life Services - New Castle during CMS and state inspections, most recent first.
A facility failed to make grievance forms accessible and did not provide wheelchair-dependent residents independent access to the grievance box at the main entrance for anonymous filing. Resident Council members said they did not know where the box was or how to get forms, and an observation showed no forms near the box and that a wheelchair-bound resident could not deposit a form without assistance. The NHA confirmed residents had to request forms from staff, which did not preserve anonymity.
The facility failed to give two residents or their representatives written bed-hold notices after hospital transfer and failed to send required clinical information with hospital transfers for multiple residents. The affected residents had complex conditions including A-fib, G-tube dependence, dementia, CKD, COPD, CHF, Parkinson's disease, sepsis, and cerebral infarction, and progress notes documented their transfers to the hospital. The NHA confirmed the missing documentation and communication.
Respiratory care equipment was not kept clean or stored per policy for multiple residents receiving oxygen and nebulizer therapy. Observations found nebulizer masks and nasal cannulas left on beds, bedside tables, wheelchairs, or concentrators instead of being placed in plastic bags when not in use, and one resident’s oxygen concentrator was dusty with an empty humidifier bottle. The NHA and DON confirmed the equipment was not changed timely and that one resident’s unused oxygen equipment should have been removed, cleansed, and stored.
Opened insulin pens and multi-dose vials were found improperly labeled or kept past their use dates in medication carts and a med storage room. An insulin pen lacked an opened or use-by date, one insulin vial remained in use after its use-by date, and an opened Tubersol vial had no use-by date and was past the 30-day limit. An LPN confirmed the labeling and discard issues.
Failure to Address Resident Council and Food Committee Concerns: Residents repeatedly reported that snacks were not being passed or made available, dining room staffing was inadequate, condiments were missing from meal trays, and fish was being served too often. Resident Council and Food Committee minutes did not show discussion of prior concerns or any responses, actions, or rationale from facility staff, and the NHA, SW, and Activities Director confirmed there was no evidence that concerns were addressed in the meeting records.
A resident with diagnoses including DM2, Charcot's joint, HF, and COPD received PRN hydroxyzine for anxiety under repeated physician orders. The MAR showed doses were administered on multiple occasions, but the DON confirmed the medication lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.
A resident’s care plan was not updated to reflect that an indwelling catheter had been discontinued, even though the physician order and MDS showed no catheter. In another case, a resident with dementia, weight loss, muscle weakness, and anxiety had a care plan meeting where the resident representative was not shown to have been invited or informed, and the DON, SW, and NHA confirmed the lack of documentation.
Incomplete hospice documentation was identified for a resident with dementia, kidney disease, HF, and Type 2 DM who was receiving hospice services. The resident’s chart did not contain current hospice communication or complete records of services furnished, and the NHA confirmed that more recent hospice documentation should have been available to the survey team.
Unsafe food handling and improper storage in resident pantries: A dietary aide was observed handling resident trays without a hair net or beard restraint during tray line, and the Dietary Manager confirmed the required coverings were not being worn. Surveyors also found expired resident food, unlabeled food, and ice packs used for resident care stored with resident food in two pantry areas; an LPN and a CNA confirmed the items were expired or improperly stored.
Failure to follow EBP was identified when an LPN completed wound care for a resident with pressure ulcers without wearing a gown, despite door signage and facility policy requiring gown and glove use for high-contact care. The resident had diabetes, ESRD, and HTN, and the record showed an order for EBP every shift. The LPN confirmed the gown was not worn and said it was not clear whether it was required.
The facility failed to ensure that required nursing staffing information was posted daily. During an observation, surveyors found that the daily staffing posting was not publicly posted, and the NHA confirmed the posting was missing.
The facility failed to keep complete resident records when several residents’ personal property inventories were missing required signatures or were not documented at all. In addition, one resident’s chart lacked meal intake percentages for multiple meals over several months, and the NHA confirmed the documentation was incomplete and that staff should record intake after each meal.
The facility did not provide written notice or obtain agreement from residents or their responsible parties before making room changes for multiple residents with conditions such as diabetes, hypertension, heart failure, and dementia. Documentation lacked evidence of required notifications, and this was confirmed by the Nursing Home Administrator.
Four newly admitted residents with complex medical conditions did not have baseline care plans initiated or written summaries of care plans and order summaries provided to them or their representatives within 48 hours of admission, as required. Clinical records lacked evidence of these actions, and staff confirmed the deficiency.
The facility did not maintain safe storage of ice due to the kitchen ice machine's drain hose resting directly on an unclean floor drain without the required air gap, as confirmed by the Maintenance Director and manufacturer guidelines.
Two residents with indwelling foley catheters did not have privacy covers on their catheter bags, resulting in the bags being visible from the corridor. Both residents had significant medical conditions and required catheters, and the DON confirmed that privacy covers should have been in place according to facility policy.
A resident with moderate cognitive impairment and multiple health conditions experienced a significant change in condition, including respiratory distress and new medical interventions. Despite facility policy requiring notification, there was no documentation that the resident's representative was informed of these changes, and the resident expressed a desire for family notification. Staff interviews confirmed the lack of documentation and notification.
A resident with an indwelling Foley catheter did not have physician orders in place for the catheter or related care, and was observed with a urinary drainage bag on the floor and without a privacy cover, contrary to facility policy. The DON confirmed these deficiencies during interviews.
Three residents with respiratory conditions were found using oxygen concentrators with filters covered in dust and gray debris, and in two cases, oxygen tubing and nasal cannulas were observed lying on the floor. Facility policy required regular cleaning of filters, but this was not done, and the DON confirmed the equipment was not maintained as required.
A resident with end stage renal disease and a standing order for dialysis three times weekly did not have their dialysis communication binder available in the facility. The binder, which should contain essential information exchanged between the facility and the dialysis center, could not be located or reviewed. Both the DON and the Administrator confirmed the binder was not accessible, resulting in incomplete and inaccurate dialysis-related records.
Staff did not label opened multi-dose insulin vials with the date of opening in two medication carts, contrary to facility policy and manufacturer instructions. This made it impossible to determine how long the insulin vials had been in use, as confirmed by an RN during surveyor observations.
A resident with an indwelling catheter and wounds did not have enhanced barrier precautions (EBP) implemented as required, including missing signage and physician orders, despite facility policy and CDC guidelines mandating these infection control measures for high-contact care activities.
The facility did not meet the required nurse aide staffing ratios on several occasions across different shifts. On specific days, the number of NAs working was below the required number for the resident census, particularly affecting the overnight shift. The Nursing Home Administrator confirmed these staffing shortages during an interview.
The facility did not meet the required LPN staffing ratios, failing to provide the mandated number of LPNs per residents during both day and overnight shifts on several occasions. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on two occasions, providing only 2.96 and 3.16 hours on those days. This was confirmed by the Nursing Home Administrator after a review of staffing documents.
The facility failed to maintain kitchen equipment and sanitary operations, with observations revealing unclean ovens and stovetops, and lapses in the cleaning schedule. Additionally, a Dietary Aide was observed preparing coffee without a beard restraint, contrary to the facility's sanitary practices policy. The Dietary Manager confirmed these deficiencies.
A resident with depression, high blood pressure, and anxiety requested Benadryl for itchiness on two occasions, but the facility failed to notify the medical provider as required by policy. The clinical record showed a typed note to the physician with a handwritten response, but lacked documentation of physician notification on the dates of the requests. The DON confirmed the absence of evidence regarding the notification.
A multi-dose vial of Aplisol-PPD in a medication room was found opened and in use without an opened date label, contrary to manufacturer's instructions and facility policy. The DON confirmed the oversight.
Grievance Forms and Anonymous Access Not Accessible
Penalty
Summary
The facility failed to make grievance forms accessible and failed to provide wheelchair-dependent residents access to the grievance box at the main entrance so they could file grievances anonymously. The facility policy stated that residents could communicate concerns or grievances verbally or by completing a Concern Form, with forms available from the NHA, DON, SSD, or at nurse's stations. During an interview with Resident Council members, they stated they did not know where the grievance box was or how to get forms to file a concern anonymously. An observation of the grievance box at the front entrance showed there were no grievance forms located near the box, and a wheelchair-bound resident could not deposit a form into the top opening without assistance. The NHA confirmed that residents had to request a form from staff and acknowledged that this did not maintain the anonymity of filing a confidential grievance.
Failure to Provide Bed-Hold Notice and Transfer Information
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to the resident and/or resident representative upon or within 24 hours of transfer for two residents reviewed for hospitalization. Facility policy stated that during a hospitalization or therapeutic leave, the resident is to be offered the opportunity to reserve residency and is asked to sign and date the notice and return it to the facility. The clinical records for two residents lacked evidence that this notice was provided after hospital transfers. The facility also failed to ensure that necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for six residents reviewed for hospitalization. Facility policy stated that transfer documents may include the face sheet, advance directive/POLST, physician orders, MAR, diagnosis, history and physical, scheduled appointments, recent lab work, and other requested information to promote continuity of care. Clinical records for multiple residents lacked evidence that this information was sent with the transfer. The affected residents had significant medical histories, including A-fib, gastrostomy tube, dementia, CKD, GERD, HTN, sepsis, neurogenic bladder, anemia, COPD, CHF, Parkinson's disease, and cerebral infarction with diabetes and HTN. Progress notes documented transfers to the hospital for each resident involved, and the NHA confirmed during interview that the bed-hold notices and required clinical information were not documented as provided for the identified residents.
Respiratory equipment not cleaned, dated, or stored properly
Penalty
Summary
The facility failed to promote cleanliness and help prevent the spread of infection related to respiratory care equipment for seven residents who used oxygen or nebulizer therapy. Facility policies required oxygen concentrator water bottles to be changed weekly, concentrators to be cleaned when soiled, nasal cannulas to be replaced every seven days and stored in plastic bags when not in use, and small volume nebulizer equipment to be rinsed, dried, dated, and stored in labeled bags with tubing replaced every seven days. Resident R7 had diagnoses including dementia, kidney disease, heart failure, and type 2 diabetes, and had an order for DuoNeb via nebulizer every six hours. On observation, the resident’s nebulizer mask was dated 5/11/26 and was lying on the bedside stand, not stored in a plastic bag. Resident R24 had COPD, depression, shortness of breath, a suicide attempt, and anxiety, and had an order for oxygen at 2 lpm as needed. On observation, the resident’s oxygen tubing with nasal cannula was lying across the bed and was not stored in a plastic bag. Resident R31 had respiratory failure, COPD, heart failure, and pleural effusion, with orders for oxygen at 2 lpm continuously and DuoNeb twice daily; the nebulizer mask was lying on the bedside table, and the oxygen tubing with nasal cannula was lying on the wheelchair seat and was not stored in a plastic bag. Resident R41 had COPD, irregular heartbeat, heart failure, and respiratory failure, with an order for oxygen at 3 lpm via nasal cannula continuously at bedtime; the oxygen tubing with nasal cannula was lying over the top of the concentrator and was not stored in a plastic bag. Resident R75 had COPD, irregular heartbeat, dementia, and atherosclerotic heart disease, with an order for oxygen as needed to keep saturation above or equal to 92%; the most recent documented oxygen use was months earlier, yet the oxygen tubing was still dated, lying over the concentrator, the humidifier bottle was empty, and the concentrator cannister was covered in dust. Resident R87 had COPD, heart failure, atherosclerotic heart disease, and peripheral vascular disease, with oxygen ordered as needed; the oxygen tubing with nasal cannula was lying on top of the concentrator, the external cannister was dusty, and the humidifier bottle was empty. Resident R155, newly admitted with COPD, stroke, atherosclerotic heart disease, and sleep apnea, had an order for ipratropium bromide four times daily, and the nebulizer mask was lying on the bed, not dated, and not stored in a plastic bag. The NHA and DON confirmed the equipment was not changed timely and should have been stored in a plastic bag when not in use, and that R75’s oxygen concentrator and tubing should have been removed from the room, cleansed, and placed in storage.
Improper Labeling and Storage of Opened Medications
Penalty
Summary
Drugs and biologicals used in the facility were not consistently labeled in accordance with accepted professional principles and were not all stored properly. Review of the facility policy showed that once a medication is opened, the nurse is to place a date-opened sticker on the medication and enter the date opened and new expiration date, with the expiration date generally 30 days unless otherwise specified. During observation of the 2 West nursing unit Cart 2, one insulin Solostar pen was found opened and in the drawer for use without an opened date or use-by date. Additional observations found other opened medications that were past their labeled use dates or lacked required dating. In the 2 East nursing unit Cart 2, one opened multi-dose insulin vial was labeled with an opened date of 4/19/26 and a use-by date of 5/17/26, yet it remained in the drawer for use. In the East unit medication storage room, one opened multi-dose vial of Tubersol was in the refrigerator with an opened date of 3/21/26 and no use-by date labeled. Staff confirmed the insulin vial should have been discarded because it was past the use-by date, and the Tubersol vial should have been discarded because it was past 30 days from the open date.
Failure to Address Resident Council and Food Committee Concerns
Penalty
Summary
The facility failed to respond to resident concerns raised in Resident Council and Food Committee meetings over a three-month period. In the 2/24/26 Food Committee minutes, residents reported they were not receiving evening snacks and requested that the snack cart be left by the nurse's station, but there was no evidence that concerns or resolutions from the prior meeting were discussed. In the 3/03/26 Food Committee minutes, residents again reported not receiving snacks, stated staff were not in the dining room to pass trays, requested condiment packets such as hot sauce, honey mustard, and ranch, and asked for less fish on the menu; there was no evidence that concerns or resolutions from the previous meeting were discussed. In the 4/28/26 Food Committee minutes, residents continued to report problems with snacks and requested fish only once per month, with no evidence that prior concerns or resolutions were reviewed. Resident Council minutes also lacked evidence that prior concerns and resolutions were discussed. In the 2/24/26 Resident Council minutes, residents requested that hallways be kept clear for better mobility and asked for increased rounds by Nurse Aides on the 2 [NAME] Unit, but there was no evidence that concerns or resolutions from the previous meeting were discussed. In the 4/09/26 Resident Council minutes, residents reported snacks were not being distributed or always available, that snacks were left by the nurse's station and not offered to residents, that dining room staffing remained an ongoing concern, and that smoking was occurring in the dock area; again, there was no evidence that prior concerns or resolutions were discussed. The 4/28/26 Resident Council minutes also lacked evidence that concerns or resolutions from the previous meeting were discussed. During interviews on 5/19/26 and 5/20/26, Resident Council members, the NHA, SW, and Activities Director confirmed there was no evidence that facility staff provided responses, actions, or rationale regarding the concerns raised.
PRN Psychotropic Medication Continued Without Required Clinical Rationale
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication beyond 14 days for Resident R6. Resident R6 was admitted with diagnoses including Type 2 diabetes, Charcot's joint of the ankle and foot, heart failure, and COPD. The clinical record showed a physician's order for hydroxyzine 25 mg by mouth every eight hours as needed beginning on 10/14/25 and discontinued on 3/17/26, and the MAR showed the medication was administered twice on 12/28/25. The record then showed another physician's order for hydroxyzine 25 mg by mouth every eight hours as needed beginning on 3/17/26 and discontinued on 4/22/26, with MAR documentation that the medication was given on 3/22/26 and 4/15/26. The current physician's orders included hydroxyzine 25 mg by mouth every eight hours as needed with a discontinue date of 10/22/26. During interview on 5/21/26, the DON confirmed that Resident R6's hydroxyzine lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days.
Care Plans Not Updated and Representative Not Invited to Care Conference
Penalty
Summary
The facility failed to review and revise a comprehensive care plan for a resident with diabetes, ESRD, and high blood pressure so that it reflected current care and services. The resident’s physician ordered discontinuation of an indwelling catheter on 12/26/25, and the MDS completed with an ARD of 3/16/26 coded the resident as not having an indwelling catheter. However, the resident’s care plan still contained an active goal stating, “I have an indwelling catheter r/t disease process - Kidney Failure,” with an initiated date of 1/6/25, a revision date of 3/15/26, and a target date of 6/10/26. During interview, the DON confirmed the care plan should have been updated to reflect that the indwelling catheter had been discontinued. The facility also failed to ensure that a resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of the person-centered care plan. The resident had diagnoses including dementia, weight loss, muscle weakness, and anxiety, and the facility policy stated that caregivers are invited to attend the care conference and that the home will call the resident representative if the representative does not accompany the resident during admission. The resident representative stated he/she did not attend the care plan meeting and did not recall being invited. The Social Worker confirmed the record lacked evidence that the resident representative was informed or invited to the care plan meeting, and the NHA confirmed the facility could not provide proof that the resident and representative were invited.
Incomplete Hospice Documentation
Penalty
Summary
The facility failed to maintain current, complete hospice service information for one resident. Resident R7 was admitted with diagnoses including palliative care, dementia, kidney disease, heart failure, and Type 2 diabetes, and a physician order indicated hospice services were effective 12/26/25. The hospice/facility agreement required complete, accurate, and detailed clinical records for each resident, but the resident’s record showed the most recent hospice communication/record of services furnished was dated 4/14/26. During interview, the Nursing Home Administrator confirmed that the most recent hospice communication was dated 4/17/26, that documentation regarding Resident R7’s hospice services was not complete, current, or available to the survey team, and that more recent communication records should have been available.
Unsafe food handling and improper storage in resident pantries
Penalty
Summary
The facility failed to serve food in a safe and sanitary manner during tray line and failed to store food in accordance with food safety standards in two resident pantries. During tray line, a dietary aide was observed carrying resident food trays without a hair net or beard net/restraint. The Dietary Manager confirmed at the time of observation that the aide was not wearing the required hair net and beard net/restraint while handling resident food and stated that these items should be worn in the dietary department. In the 1 [NAME] pantry refrigerator, surveyors observed containers of honey thick apple juice with use-by dates of 2/27/26 and 2/24/26, containers of dairy drink with a best-used-by date of 1/15/26, a box of pizza without a resident name or date, and several ice packs used for resident care stored next to resident food. An LPN confirmed the expired food, the unlabeled pizza, and the ice packs stored with food, and stated the juice and milk should have been discarded by their expiration date, the pizza box should have had a resident name and date, and the ice packs used on residents' bodies should not be stored with food. In the East Wing pantry freezer, surveyors observed a bag of frozen broccoli with a resident name and expiration date of 12/14/25 and two ice packs used for resident care stored next to resident food. A CNA confirmed the broccoli was expired and that the ice packs should not be stored with food.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified when facility staff did not follow enhanced barrier precautions during wound care for Resident R5. The facility policy for Enhanced Barrier Precautions, dated 1/13/26, stated that EBP are used to prevent the spread of multi-drug organisms and that gloves and gowns are to be applied before high-contact resident care activities, including wound care. Resident R5 was admitted on 1/13/24 and had diagnoses including diabetes, ESRD, and high blood pressure. The clinical record also showed a physician order dated 3/12/26 for Enhanced Barrier Precautions every shift. During observation of wound care on 5/18/26 at approximately 2:40 p.m., signage on R5's door indicated that EBP were required and that gown and gloves were to be used. An LPN entered the room and completed wound care without putting on a gown. During interview, the LPN confirmed that a gown was not worn before entering the room or before completing wound care and stated uncertainty about whether a gown was required because it was not clear. The Nursing Home Administrator later confirmed that the LPN should have worn a gown prior to entering the room for wound care, consistent with facility policy and the posted signage.
Daily Nursing Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure that the required nursing staffing information was posted on a daily basis. During observations on 5/19/26 at 10:25 a.m., surveyors found that the daily staffing posting was not publicly posted in the facility. The Nursing Home Administrator confirmed at the time of the observation that the posting was missing.
Incomplete Resident Records and Missing Meal Intake Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six residents by not properly documenting inventories of personal belongings and, for one closed record, by not documenting meal intake as required. Facility policy stated that an inventory of belongings must be completed at admission, transfer, or discharge, documented on the inventory form, and signed by staff and the resident or family, with two signatures required. Resident R3’s inventory sheet lacked resident and staff signatures, Resident R19’s record lacked evidence that an inventory of personal effects was completed and signed, Resident R59’s record lacked evidence that an inventory of personal effects was completed and signed, Resident R87’s inventory sheet lacked staff signatures, Resident R114’s record lacked evidence that an inventory of personal effects was completed and signed, and Closed Record CR150’s record lacked complete documentation of meal intake percentages for multiple meals across several months. Resident CR150’s record showed diagnoses including protein calorie malnutrition, atrial fibrillation, and high blood pressure. The task for Amount Eaten had missing documentation for multiple meal opportunities in December 2025, January 2026, February 2026, and March 2026. During interview, the Nursing Home Administrator confirmed that the record lacked documentation for each meal as required and stated that staff should document residents’ meal intake after each meal.
Failure to Provide Written Notice Prior to Resident Room Changes
Penalty
Summary
The facility failed to provide written notice to residents and/or their responsible parties prior to making room changes for five out of seven residents reviewed. According to the facility's policy, the Social Worker is responsible for contacting family members or responsible parties to discuss room changes. However, clinical records for the affected residents did not contain evidence that residents were asked for their agreement to the room change or that written notification, including the reason for the change, was provided before the move occurred. The residents involved had various medical conditions, including diabetes, hypertension, anxiety, heart failure, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and vascular dementia. Documentation for each resident showed that room changes were made, but there was no record of written notification or consent prior to these changes. The Nursing Home Administrator confirmed during an interview that the required written notifications were not present in the clinical records for these residents.
Failure to Initiate and Communicate Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to residents and/or their representatives for four out of thirteen residents reviewed. Specifically, clinical records for these residents did not contain evidence that a baseline care plan was created within 48 hours of admission, nor that a summary of the care plan and physician orders was provided to the resident or their representative, as required. This deficiency was confirmed through clinical record review and staff interviews, and no facility policy regarding this process was provided. The residents affected had significant medical conditions, including dementia with severe cognitive impairment, protein-calorie malnutrition, pneumonia, malignant neoplasm of the prostate, sleep apnea, end stage renal disease, high blood pressure, kidney failure, diabetes, and amputation. Despite these complex needs, there was no documentation that their immediate care needs were assessed and planned for upon admission, nor that this information was communicated to them or their representatives.
Improper Ice Machine Drainage and Storage
Penalty
Summary
The facility failed to maintain safe storage of ice for residents by not ensuring the proper installation of the kitchen ice machine's drain hose. Review of manufacturer guidelines indicated that an air gap should be maintained between the drain tube and the floor drain. However, observations revealed that the ice machine hose drain was resting directly on the floor drain, with no vertical air gap present. The floor drain and the surrounding area were noted to be rusty and unclean. The Maintenance Director confirmed that the lack of an air gap allowed the hose drain to rest on the unclean floor drain, resulting in unsafe storage conditions for ice.
Failure to Maintain Privacy and Dignity for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure the privacy and dignity of residents with indwelling urinary catheters, as required by facility policy and resident rights regulations. Observations revealed that two residents with foley catheters did not have privacy covers on their catheter bags, making the bags visible from the corridor. One resident was observed sitting in a wheelchair with the catheter bag secured under the seat but lacking a privacy cover, and the resident expressed a desire for a privacy cover. Another resident was observed lying in bed with the catheter drainage bag on the floor, also visible from the corridor and without a privacy cover. Both residents had significant medical histories, including kidney failure, cellulitis, amputation, and diabetes, and had physician orders or documentation for indwelling foley catheters. The Director of Nursing confirmed during an interview that the catheter bags should have had privacy covers in place, as per facility policy. The deficiency was cited under resident rights and nursing services regulations.
Failure to Notify Resident's Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition and new treatments, as required by facility policy and regulatory standards. The resident in question had a history of Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, and obesity, and was identified as having moderate cognitive impairment with a BIMS score of 8/15. On the date in question, the resident experienced acute respiratory symptoms, including low oxygen saturation, irregular heart rate, and purple nail beds, which led to the administration of breathing treatments, diuretics, and steroids. The medical provider documented that the resident was high-risk and had a significant change in condition, resulting in new orders for antibiotics, steroids, and other medications. Despite these significant clinical changes and interventions, there was no documentation in the clinical record that the resident's representative was notified of the change in condition or new treatments. Interviews with the NHA and DON revealed that staff believed the resident did not want family notified, but there was no documentation to support this, and the resident stated a preference for family notification. The facility's policy required documentation of such notifications, including who was informed and their response, but this was not present in the record.
Failure to Ensure Physician Orders and Proper Catheter Care
Penalty
Summary
The facility failed to ensure that adequate physician orders were in place for an indwelling urinary catheter and did not provide appropriate catheter care for one resident. Review of the resident's clinical record showed that the individual was admitted with an indwelling Foley catheter, but there was no evidence of physician orders for the catheter or related care. Facility policy requires verification of physician orders for indwelling catheters and specifies proper handling and placement of catheter bags. Observations revealed that the resident's urinary drainage bag was placed on the floor, visible from the corridor, and lacked a privacy cover, which is contrary to facility policy. The Director of Nursing confirmed both the absence of physician orders for the catheter and that the catheter bag should not have been on the floor and should have had a privacy cover. These findings demonstrate a failure to follow established protocols for catheter care and documentation.
Failure to Maintain Clean Respiratory Equipment and Prevent Infection
Penalty
Summary
The facility failed to maintain cleanliness and prevent the spread of infection in the provision of respiratory care equipment for three residents. Observations revealed that the oxygen concentrator filters for all three residents were covered with a large amount of gray, fluffy substance, indicating that the filters had not been cleaned as required by facility policy. The policy specified that filters should be removed, rinsed, and dried weekly or more often if needed to keep them clean and free of dust. Additionally, for two residents, the oxygen tubing and nasal cannula were found lying on the floor, which was confirmed by both resident statements and staff interviews. The residents involved had significant medical conditions, including obstructive sleep apnea, end stage renal disease, high blood pressure, chronic obstructive pulmonary disease, respiratory failure, and obesity. Physician orders for these residents included continuous or as-needed oxygen therapy via nasal cannula. Despite these orders, the equipment used to deliver oxygen was not maintained in a sanitary manner, as evidenced by the dirty filters and tubing/cannulas in contact with the floor. The DON confirmed that the observed conditions did not meet facility standards for respiratory care equipment cleanliness.
Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident requiring dialysis services. According to the facility's agreement with the dialysis center, the facility is responsible for providing all relevant medical and administrative information about the resident, while the dialysis center is to supply the facility with updates and guidance regarding the resident's renal condition. However, review of the clinical record for a resident with end stage renal disease and a physician's order for dialysis three times weekly revealed that the dialysis communication binder, which should contain essential information exchanged between the facility and the dialysis center, was not readily available in the facility. Interviews with the resident, the DON, and the Nursing Home Administrator confirmed that the dialysis communication binder could not be located or reviewed at the time of the survey. The resident mentioned that the binder is usually kept in their wheelchair but was unsure of its current location. Both the DON and the Administrator acknowledged that the binder was not accessible, indicating a lapse in maintaining required medical records and communication as stipulated by facility policy and regulatory requirements.
Failure to Date Opened Multi-Dose Insulin Vials
Penalty
Summary
Facility staff failed to label multi-dose insulin vials with the date they were opened in two of three medication carts, as required by facility policy and manufacturer instructions. During observations, three opened and undated multi-dose insulin vials were found in one medication cart, and two opened and undated vials were found in another. The facility's policy directed staff to place a date opened sticker and record the date of opening and expiration on each vial, and the manufacturer's instructions specified that insulin vials expire 28 days after opening. A registered nurse confirmed that the vials were not dated upon opening, making it impossible to determine how long the vials had been in use.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one resident who required such measures due to the presence of an indwelling urinary catheter and ongoing wound care. According to the facility's policy and CDC guidelines, EBP—including the use of isolation gowns and gloves during high-contact care activities—are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Observations revealed that the resident's room did not have the required signage to alert staff and visitors of EBP requirements, despite the resident having both a catheter and wounds that necessitated these precautions. Interviews with the Director of Nursing confirmed that the resident's room lacked EBP signage and that the clinical record did not contain physician orders for EBP. The resident's medical history included an amputation of the left foot, diabetes, high blood pressure, and a coccyx wound, all of which increased the need for strict infection control measures. The failure to implement EBP as outlined in policy and regulatory requirements constituted a deficiency in the facility's infection prevention and control program.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum NA ratios on several occasions across different shifts. On the day shift of December 7, 2024, the facility had a census of 134 residents but only 13.27 NAs worked when 13.40 were required. On the evening shift of December 6, 2024, with a census of 136 residents, 11.97 NAs worked instead of the required 12.36. The overnight shift experienced the most significant shortages, with five days between December 2 and December 14, 2024, not meeting the required ratios. For instance, on December 2, 2024, with a census of 135 residents, only 6.70 NAs worked when 9.00 were required. The Nursing Home Administrator confirmed during an interview on January 3, 2025, that the facility did not meet the minimum NA ratios for the specified days and shifts. This acknowledgment indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements. The report does not provide details on any specific residents affected or the direct impact on resident care, focusing instead on the staffing discrepancies and the facility's acknowledgment of these deficiencies.
Plan Of Correction
The facility was unable to make corrective action for the (nurse aide ratio) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing or designee will re-educate the labor manager and the Registered nurse supervisors on the 7/1/2024 requirements for Nurse aide ratios. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Nursing home administrator, Director of Nursing, and Labor manager will conduct daily staffing meetings Monday - Friday to review (nurse aide ratios) throughout the day, the following day, and the weekend. In the event of vacancies, the Labor Manager or designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. Nursing Home Administrator or designee will audit daily staffing ratios and along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain a minimum of one LPN per 25 residents during the day shift on December 10, 2024, when only 5.00 LPNs were available for a census of 132 residents, falling short of the required 5.28 LPNs. Additionally, the facility did not meet the minimum requirement of one LPN per 40 residents on the overnight shift for five days within the reviewed period. On December 3, 6, 7, 10, and 14, 2024, the number of LPNs working was consistently below the required number based on the resident census for each of those nights. The Nursing Home Administrator confirmed these staffing shortages during an interview on January 3, 2025.
Plan Of Correction
The facility was unable to make corrective action for the (Licensed Practical Nurse ratio) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 Licensed Practical Nurse ratio requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Nursing Home Administrator, Director of Nursing, and Labor manager will conduct daily staffing meetings Monday - Friday to review (Licensed Practical Nurse ratios) throughout the day, the following day, and the weekend. In the event of vacancies, the Labor Manager or designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. Nursing Home Administrator or designee will audit daily staffing ratios along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day on two specific days. On December 6, 2024, the facility provided only 2.96 hours per patient day (PPD), and on December 11, 2024, it provided 3.16 PPD. This deficiency was identified through a review of the facility's nursing staffing documents covering the period from December 1, 2024, to December 14, 2024. The Nursing Home Administrator confirmed during a telephone interview that the facility did not meet the required minimum nursing care hours on these dates.
Plan Of Correction
The facility was unable to make corrective action for the minimum number of general nursing care hours for the identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 for PPD requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Nursing Home Administrator, Director of Nursing, and Labor manager will conduct daily staffing meetings Monday - Friday to review nursing staffing throughout the day, the following day, and the weekend. In the event of vacancies, the Labor manager or Designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier to ensure shifts are filled and facility meets PPD requirements. Nursing Home Administrator or designee will audit daily staffing PPD along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
Failure to Maintain Kitchen Sanitation and Employee Hygiene
Penalty
Summary
The facility failed to maintain kitchen equipment and sanitary operations in the main kitchen, as evidenced by observations and staff interviews. The facility's policy required daily cleaning of ovens and stovetops, with a more thorough monthly cleaning schedule. However, observations revealed that the stovetops and ovens were not cleaned as per the schedule, with dried food, debris, and aluminum foil found inside the ovens. The facility's records showed significant lapses in the cleaning schedule, with the oven not cleaned for eight of the last ten months and the stove not cleaned for seven of the last nine months. The Dietary Manager confirmed these findings during an interview. Additionally, the facility's policy on employee sanitary practices required all employees to wear hair restraints to prevent hair from contacting exposed food. However, during an observation of the tray line, a Dietary Aide was seen preparing coffee for residents without a beard restraint, despite having a beard of sufficient length that required one. The Dietary Manager confirmed that the employee should have been wearing a beard restraint, indicating a failure to adhere to the facility's sanitary practices policy.
Failure to Notify Physician of Resident's Treatment Needs
Penalty
Summary
The facility failed to notify a medical provider of a need to alter treatment due to resident symptoms and/or complaints for one of seven residents reviewed. The facility's policy requires staff to communicate changes in a resident's condition to the physician and document the notification and response. However, the clinical record of a resident with diagnoses including depression, high blood pressure, and anxiety, showed that the resident requested Benadryl for itchiness on two occasions, but there was no evidence that the medical provider was notified of these complaints. The resident's clinical record contained a typed note to the physician indicating a request for Benadryl, with a handwritten response lacking a date and time. Despite this, there was no progress note correlating with the typed note and response, and no evidence of physician notification on the dates the resident requested Benadryl. The Director of Nursing confirmed the lack of documentation regarding the notification of the medical provider about the resident's complaints and requests.
Failure to Label Multi-Dose Vial of Aplisol
Penalty
Summary
The facility failed to label a multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD) injection with the date it was opened in one of the medication storage rooms, specifically in Two East Hall. According to the manufacturer's instructions, vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. The facility's policy on medication storage, last reviewed on June 27, 2023, mandates that medications and biologicals be stored safely and properly, following the manufacturer's recommendations. During an observation on June 14, 2024, at approximately 10:30 a.m., it was noted that the vial was opened and in use but lacked an opened date label. The Director of Nursing confirmed the vial was undated and in daily use, acknowledging it should have been labeled with the date it was opened.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Castle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Care Center | 0.2 mi | ★★★★★ | 18 | 0 |
| Haven Convalescent Home, Inc | 0.6 mi | ★★★★★ | 2 | 0 |
| Edison Manor Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 9 | 1 |
| Kadima Rehabilitation & Nursing At New Castle | 1.7 mi | ★★★★★ | 18 | 0 |
| Jameson Nursing And Rehab Center | 4.3 mi | ★★★★★ | 4 | 0 |
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