Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Richland Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors identified that dietary staff did not follow facility policies for safe food service. A dietary employee with a beard was observed preparing and plating food without a required beard restraint, contrary to the facility’s hair restraint policy. Review of kitchen temperature logs showed multiple days with missing or incomplete food temperature recordings, despite a policy requiring temperatures to be checked and documented before tray assembly to ensure proper serving temperatures.
A resident with C-diff, who was cognitively intact and required staff assistance with daily care, was ordered to receive Metronidazole and then had the order changed to Dificid 200 mg BID for 10 days. Nursing notes documented that the facility was waiting for the Dificid to arrive and later that the pharmacy reported it was a high-cost medication requiring additional payment and insurance information, but the resident’s MAR showed no Dificid doses were administered after the order was written. There was no documentation that the physician was notified that the medication was unavailable or that the resident was not receiving the ordered treatment, despite the resident reporting she had been waiting for her antibiotic and asking staff about it. The DON confirmed that the physician should have been informed that the ordered Dificid was not available and had not been given.
Care plans did not reflect the specific needs of two residents. One resident with dementia and PTSD had no documented care plan evidence addressing PTSD or trigger-specific interventions, despite a policy requiring individualized trauma-informed care. Another resident with cognitive impairment, anxiety, and depression had no documented comprehensive care plan for the need for an antipsychotic medication after an order for Olanzapine was added; the DON confirmed the missing documentation.
Failure to Follow Lisinopril Hold Parameters: A resident with heart disease and HTN had a physician order for lisinopril 2.5 mg daily with instructions to hold if SBP was 120 mm/Hg or less. MAR review showed multiple doses were given when BP was at or below the hold parameter, and two doses were missed when BP was within range to receive the medication. The ADON confirmed the medication was not held or administered as ordered.
Improper Catheter Tubing Placement: A resident with an indwelling urinary catheter for urinary retention was observed with the catheter tubing in direct contact with the floor while the drainage bag hung beside the bed in a privacy bag. A Nurse Aide and the DON both confirmed the tubing should not have been on the floor, and the facility policy required catheter tubing and the drainage bag to be kept off the floor.
A resident with dementia and PTSD was not assessed for trauma-informed care, and the facility did not identify specific triggers or document measures to prevent or minimize re-traumatization. The resident’s care plan noted PTSD and dementia, but there was no evidence of a trauma-informed assessment. The SW stated the facility was not completing these assessments.
An open Humalog KwikPen for one resident and open NovoLog and Degludec FlexTouch pens for another resident were found in a cart without dates and without caps. Facility policy and package inserts required opened medications to be dated, and both an LPN and the DON confirmed the pens should have been dated when opened and capped.
Failure to Provide Ordered Adaptive Eating Equipment: A resident with cognitive impairment, monoplegia after a CVA, and limited ROM needed set-up assistance and had an order for an inner lip plate for meals. During breakfast, the resident was observed eating from a regular plate, having difficulty getting food onto the fork, and spilling food onto the chest; an LPN and the DON confirmed the ordered adaptive equipment was not provided.
Improper Food Storage and Spoilage in Kitchen and Resident Refrigerator: Surveyors found moldy cucumbers in the walk-in cooler, multiple opened and undated food items in the freezer and kitchen refrigerator, and undated soup with visible residue in a resident refrigerator. The Dietary Director confirmed that opened food should be dated, properly sealed, and that resident food showing signs of spoilage should be discarded.
A resident with multiple complex diagnoses was found to have two Exelon transdermal patches applied simultaneously, contrary to physician orders requiring removal of the old patch before applying a new one. Documentation and staff interviews indicated the patch was administered as ordered, but the resident was discovered at the hospital with both patches still on, confirming the old patch was not removed as required.
A resident at Richland Nursing and Rehab, with a history of CHF and pneumonia, did not receive oxygen therapy as ordered, leading to a drop in oxygen saturation. During a transfer, two nurse aides removed the resident's oxygen and failed to reapply it, resulting in an oxygen saturation reading of 87%. Interviews confirmed the oversight, and the DON acknowledged the lapse in care.
The facility failed to maintain its kitchen fire suppression system as required by NFPA 101 standards. The semi-annual inspection was overdue, and there was no documentation for monthly visual inspections. These issues affected one of seven smoke compartments and were confirmed by the Facility Administrator and Maintenance Supervisor.
The facility failed to maintain corridor doors, with a hole above the medication room door knob and a non-latching door to room C132, affecting two smoke compartments. These deficiencies were confirmed by the Facility Administrator and Maintenance Supervisor.
The facility did not follow its pre-approved menu and recipes for a lunch meal, resulting in residents not receiving a dinner roll, margarine, or cream with pineapple tidbits. The chicken vegetable stew was missing several ingredients. Staff cited a supply truck delay as the reason for these omissions, and there was no evidence of communication with the resident council president about the menu changes.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers and reasons for hospitalization for six residents. These included cases of urinary tract infections, heart attack, altered mental status, and status epilepticus. The DON confirmed the lack of required notifications, violating resident rights and discharge policy regulations.
The facility failed to clarify physician orders for three residents, leading to deficiencies in care. One resident's feeding tube order was not updated despite oral medication administration. Another resident missed insulin doses due to outdated orders. A third resident received Midodrine without proper order clarification for specific blood pressure ranges.
The facility failed to complete neurological checks per protocol for a resident after a fall and did not administer medications as ordered for another resident. One resident, with cognitive impairment and vascular issues, showed symptoms of distress after a fall, but the required neurological assessments were not completed. Another resident, with heart failure and hypotension, received Midodrine despite having a systolic blood pressure above the prescribed threshold. The ADON confirmed these lapses in protocol adherence.
The facility failed to account for controlled medications for two residents. One resident, cognitively intact, was missing 60 tablets of Oxycodone prescribed for chronic pain. Another resident, moderately cognitively impaired, was missing 60 tablets of Oxycodone prescribed for polyneuropathy. Investigations confirmed the missing medications, but the facility could not locate them.
The facility failed to maintain effective infection control practices, as evidenced by an LPN not using a gown during wound care for a resident on EBP, improper hand hygiene during wound care for another resident, and handling medications with bare hands. Additionally, a resident with a dialysis catheter lacked appropriate EBP signage.
A facility failed to ensure a resident's call bell was within reach, as required by policy. The resident, who was cognitively impaired and dependent on staff, was observed asking for the call bell, which was found in a nightstand drawer, out of reach. A nurse aide and the DON confirmed the call bell should have been accessible.
The facility failed to notify residents and/or their responsible parties about the bed-hold policy upon hospital transfer for three residents. One resident was transferred due to a large emesis and abdominal pain, another due to altered mental status, and a third after a fall. The Director of Nursing confirmed the lack of documentation for these notifications, which was identified as a concern by the new Business Office Manager.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting medical conditions and treatments. Errors included incorrect coding of injections, nephrostomy tubes, insulin, antibiotics, and antipsychotic medications, as confirmed by staff interviews.
The facility failed to update care plans for four residents, leading to discrepancies between documented care needs and actual conditions. A resident with a Central Venous Catheter for dialysis had a care plan indicating a fistula, while another resident's resolved infection was not reflected in their care plan. Additionally, two residents with resolved or reopened pressure injuries did not have updated care plans. These oversights were confirmed by the facility's nursing leadership.
A resident with a Stage 4 pressure ulcer did not receive wound care as ordered by the physician. The LPN failed to apply medical grade honey and Calcium Alginate to the resident's left great toe, as prescribed. Instead, the LPN only used Acetic Acid and a dressing, which was confirmed by interviews with the LPN and the ADON/Infection Control Preventionist.
A facility failed to flush a resident's intravenous catheter as per policy, which required flushing to maintain patency and prevent medication mixing. Despite physician orders to flush the PICC line with saline every shift, staff administered Ertapenem Sodium daily without documented evidence of flushing. This was confirmed by the DON and ADON.
The facility failed to properly label and store medications, including undated inhalers and a discontinued insulin pen in the B-wing med cart. The medication refrigerator's temperature was inconsistently monitored, and loose medications were found in the C-wing med cart. These deficiencies were confirmed by staff interviews.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated issues in quality of care, treatment of pressure ulcers, medication storage, and infection control. Despite plans to conduct audits and review results, these measures were ineffective in maintaining compliance.
The facility failed to meet the required NA-to-resident staffing ratios, with insufficient NAs on several days across different shifts. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels.
The facility failed to meet the required LPN-to-resident staffing ratios on specific days in November and December 2024. On certain days, the number of LPNs available during the day and overnight shifts was below the required levels based on the facility census. The Nursing Home Administrator confirmed these deficiencies, and no additional higher-level staff were available to compensate for the shortfall.
A facility failed to notify a resident's representative about a hospital transfer and medication changes. The resident, with moderate cognitive impairment and epilepsy, was transferred to the hospital for status epilepticus without notifying their representative. Additionally, changes in medication orders for Keppra and Pantoprazole were not communicated. The DON confirmed the lack of notification, violating the facility's policy on residents' rights.
Two residents reported that they were not allowed to use the bathroom during meal times due to an infection control policy, leading to incontinence and distress. One resident, with a cancer diagnosis, experienced frequent bowel incontinence, while another, prone to urinary tract infections, had to wait up to an hour to use the bathroom. Staff confirmed the policy, and facility leadership acknowledged it but claimed needs would be addressed individually.
Failure to Enforce Hair Restraints and Food Temperature Monitoring in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and professional standards for safe food service related to hair restraints and food temperature monitoring. The facility’s hair restraint policy, dated November 26, 2025, required dietary staff to wear hair nets or caps and/or beard restraints when cooking, preparing, or assembling food to prevent hair from contacting exposed food and to help prevent the spread of illness. During an observation in the main kitchen on April 27, 2026, at 11:32 a.m., a dietary staff member was seen plating corn and placing beef on soft tortilla shells to make quesadillas for the lunch meal while having a beard and not wearing a beard restraint. The Dietary Manager later confirmed that this staff member was plating food without the required beard restraint and that he should have been wearing one. The facility also failed to follow its policy on recording food temperatures, dated November 26, 2025, which required that food temperatures be checked before trays are assembled to ensure food is at proper serving temperatures needed to limit the growth of pathogens capable of causing disease. Review of the April 2026 food temperature logs on April 27, 2026, at 11:50 a.m. showed multiple missing or incomplete entries: no lunch temperatures recorded for April 21 and 22; no breakfast, lunch, or supper temperatures for April 23; no breakfast or lunch temperatures for April 24; and no breakfast, lunch, or supper temperatures for April 26. The Dietary Manager confirmed that food temperatures for these dates should have been taken and recorded per facility policy, but they were not.
Failure to Administer Ordered C-diff Antibiotic and Notify Physician of Unavailable Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely administration of a prescribed antibiotic and failure to notify the physician when the medication was not available. Facility policy dated November 26, 2025, required that medications be administered safely, timely, and as prescribed, including adherence to required time frames. Resident 6’s admission MDS dated April 20, 2026, showed the resident was cognitively intact, needed staff assistance with daily care, was frequently bowel incontinent, and had a diagnosis of unspecified diarrhea. On April 23, 2026, stool specimen results showed the resident was positive for C. difficile, and the physician was notified. A physician’s order dated April 23, 2026, directed Metronidazole 500 mg three times daily for 14 days for C-diff. On April 24, 2026, a nursing note documented new orders to discontinue Metronidazole and start Dificid 200 mg twice daily for 10 days for C-diff, and a corresponding physician’s order was entered with an end date of May 4, 2026. Subsequent nursing notes on April 25 and April 26 documented that the facility was waiting for the Dificid to arrive. A note on April 27 at 5:40 a.m. recorded that a pharmacy representative reported Dificid was a high-cost medication and that payment information and an alternative medication from insurance would be sent, requiring completion and return by the DON or ADON. Another note on April 27 at 8:48 a.m. indicated the facility was still waiting for confirmation of the Dificid. Review of the April 2026 MAR showed the resident had not received any Dificid doses since the order was written on April 24, 2026, and there was no documentation that the physician was notified that the medication was unavailable and not being administered. The ADON stated that the medication was on backorder and being delivered that day. The resident reported having waited for the antibiotic since Friday and repeatedly asking staff about it. The DON confirmed that the physician should have been notified that the Dificid was not available and that the resident had not been receiving the ordered treatment for C-diff.
Care Plans Did Not Reflect PTSD Triggers or Antipsychotic Medication Needs
Penalty
Summary
The facility failed to ensure that the care plan reflected each resident’s specific care needs for two residents. For one resident with cognitive impairment, dementia, and PTSD, the quarterly MDS dated December 12, 2025, showed the resident required staff assistance with daily care needs, but there was no documented evidence that the care plan reflected the PTSD diagnosis or associated triggers. The facility policy for comprehensive care plans stated that care plans should include measurable objectives, timeframes, and individualized interventions for trauma survivors, including trigger-specific interventions to reduce exposure to re-traumatizing triggers. For another resident with cognitive impairment, anxiety, and depression, the quarterly MDS dated November 14, 2025, showed the resident required staff assistance with daily care needs and received antidepressant medications. A physician’s order dated December 31, 2025, added 5 mg of Olanzapine at bedtime related to major depression, but there was no documented evidence that a comprehensive care plan was developed to reflect the resident’s need for an antipsychotic medication. The DON confirmed that there was no documented evidence in the medical record that the care plan addressed the antipsychotic medication need.
Failure to Follow Lisinopril Hold Parameters
Penalty
Summary
The facility failed to follow physician orders for Resident 80’s lisinopril administration. Resident 80 had diagnoses including heart disease and high blood pressure and was moderately cognitively impaired with clear speech and understanding noted on the quarterly MDS assessment dated January 17, 2026. The resident had originally been ordered lisinopril 5 mg daily on May 13, 2025, and after an episode of dizziness with a blood pressure of 92/60 mm/Hg on October 8, 2025, the physician changed the order on October 9, 2025 to lisinopril 2.5 mg daily with instructions to hold the medication if systolic blood pressure was less than or equal to 120 mm/Hg. Review of the MAR for October 2025 through January 2026 showed multiple instances where lisinopril was administered when the resident’s systolic blood pressure was at or below the ordered hold parameter, including readings such as 116/78, 112/70, 108/68, 110/60, 112/66, 120/88, 112/62, and 116/58 mm/Hg. The MAR also showed two dates when lisinopril was not given despite blood pressure readings within the range to receive it, including 124/70 mm/Hg and 142/88 mm/Hg. The Assistant Director of Nursing confirmed on January 29, 2026, that the medication was not held or administered as ordered by the physician.
Improper Catheter Tubing Placement
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter related to urinary retention. The facility policy on urinary catheter care, dated November 26, 2025, stated that its purpose was to prevent catheter-associated urinary tract infections and included a general infection control guideline to keep catheter tubing and the drainage bag off the floor. Resident 94 was admitted on January 27, 2026 for a three-day respite stay, and the care plan and physician's orders dated January 28, 2026 documented the resident's indwelling urinary catheter for urinary retention. On January 28, 2026 at 1:06 p.m., observation showed Resident 94 lying in a low bed with the catheter bag hanging on the left side of the bed in a privacy bag and the catheter tubing in direct contact with the floor. A Nurse Aide confirmed at 1:09 p.m. that the tubing was lying on the floor and should not have been. Later that day, the DON also confirmed that the catheter tubing should not have been in direct contact with the floor and stated that hooks/clips had previously been used to keep the tubing off the floor.
Failure to Assess PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of dementia and PTSD was assessed for trauma-informed care and that specific triggers were identified to help minimize or prevent re-traumatization. A quarterly MDS assessment for the resident indicated cognitive impairment and a need for staff assistance with daily care needs, and the resident’s care plan documented PTSD and dementia. However, there was no documented evidence that the facility identified the resident’s specific triggers or implemented measures for staff to prevent or minimize those triggers. The facility’s trauma informed care policy stated that care should account for experiences and preferences and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. During interview, the Social Worker stated that the facility was not completing trauma informed care assessments and that they should be. The report also states that the facility did not assess or identify specific triggers that may re-traumatize residents with past traumas for this resident.
Undated Open Insulin Pens in Medication Cart
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when multi-dose medication containers in one medication cart were left undated after opening. Review of facility policy on medication storage and disposal showed that opened medication vials were to be properly dated. Package inserts for Degludec, NovoLog, and Humalog KwikPen indicated specific use periods after opening. During observation of the C hall cart, an open and undated Humalog KwikPen for Resident 31 was found, along with an open and undated NovoLog FlexPen and Degludec FlexTouch pen for Resident 94, and the pens did not have caps. An LPN confirmed the medications should have been dated when opened, and the DON also confirmed that the medications should have been dated upon opening and should have had a cap.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure that staff provided assistive devices for eating in accordance with physician orders for one resident. The resident had cognitive impairment, required set-up assistance with eating, had limited range of motion in one upper extremity, and had monoplegia following a CVA affecting the left side. The resident’s nutrition care plan indicated that adaptive equipment was to be provided as ordered, and a physician order included an inner lip plate for meals. A nutrition note also documented that the resident utilized an inner lip plate for adaptive equipment. During breakfast observation, the resident was sitting up in bed eating from a regular plate instead of the ordered inner lip plate. The resident had difficulty getting food onto the fork and had a large amount of food resting on the chest. The meal ticket on the tray indicated that the resident was to have an inner lip plate for meals. An LPN confirmed that the resident did not have the inner lip plate for breakfast and should have had it per the meal ticket, and the DON confirmed that the resident should have had the inner lip plate as ordered.
Improper Food Storage and Spoilage in Kitchen and Resident Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. Surveyors observed one quarter bushel of moldy cucumbers in the walk-in cooler, half of a box of Tony's pizzas, half of a bag of chicken tenders, and one opened box of breadsticks in the walk-in freezer that were undated and exposed to the air. In the small kitchen refrigerator, half of a container of heavy whipping cream was opened and undated. In the residents' refrigerator, half of a container of soup was undated and had a brown and white removable substance around the lid. The Dietary Director confirmed that food should be dated when opened, properly sealed for storage, and that resident food should be thrown out when it shows signs of spoilage.
Failure to Remove Old Medication Patch Prior to New Application
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not following a physician's order for medication administration for one resident. According to the facility's policy, medications are to be administered as per the written orders of the attending physician. The resident in question was moderately cognitively impaired, required extensive assistance for daily care, and had multiple diagnoses including acute respiratory failure, heart attack, stroke, myasthenia gravis, and dementia. The physician's order specified that a Rivastigmine (Exelon) transdermal patch should be applied once daily and the old patch removed per schedule. Documentation showed that the patch was administered on consecutive days as ordered, with staff indicating the old patch was removed when the new one was applied. However, a late entry nursing note indicated that the resident was found with two Exelon patches on upon arrival at the hospital. Interviews with the LPN who administered the medication and the DON confirmed that, despite the staff member's assertion that she always removes the old patch before applying a new one, the resident was discovered with two patches. The DON acknowledged that, based on the hospital's report and the facility's investigation, the old patch was not removed as required by the physician's order.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Richland Nursing and Rehab was found to be non-compliant with the requirement for respiratory care as outlined in 42 CFR Part 483.25(i). The deficiency was identified during an abbreviated complaint survey, where it was observed that the facility failed to ensure that oxygen was provided as ordered by the physician for a resident. The resident, who was severely cognitively impaired and had a history of congestive heart failure and pneumonia, was supposed to receive oxygen at zero to four liters per minute to maintain an oxygen saturation of 90 percent or more. However, during an observation, it was noted that the resident's oxygen was removed by two nurse aides during a transfer and was not reapplied, leading to a drop in the resident's oxygen saturation to 87 percent. Interviews with the nurse aides confirmed that the oxygen was not reapplied after the transfer, which was acknowledged as an oversight. The Director of Nursing also confirmed that the resident should have been provided with oxygen therapy as ordered. This incident highlights a failure in adhering to the facility's policy regarding safe oxygen administration, which required verification of the physician's order and proper application of oxygen therapy.
Plan Of Correction
1. Licensed Practical Nurse applied oxygen to Resident 3 and checked Resident's 3 oxygen saturation (measurement of the percentage of oxygen-rich hemoglobin in arterial blood) using a pulse oximeter (a device which measures the percentage of oxygen-rich hemoglobin in arterial blood) which showed Resident 3's oxygen saturation was at 94% on 2 liters of oxygen which is in line with her physician's order of her blood oxygen saturation being maintained at 90% or above. 2. At the time that it was noted that Resident 3's oxygen had not been properly reapplied post mechanical lift transfer, Admissions Coordinator, a licensed nurse, performed a set of nursing rounds to ensure other Residents ordered oxygen had it properly applied. No other Residents found to be missing their oxygen placement. 3. Education will be provided to Certified Nurses Aides to ensure that oxygen is properly reapplied to Residents after necessary removal for care tasks. 4. Licensed Practical Nurses will audit, per shift, Residents who are ordered to have oxygen to ensure that it is in place. Director of Nursing, or designee, will review three Residents per shift three times a week for two weeks, then monthly as needed, to ensure audits are being properly completed. Results will be reviewed with the Quality Assurance Performance Improvement committee.
Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically affecting one of seven smoke compartments. During a documentation review on December 23, 2024, it was found that the most recent semi-annual inspection and maintenance of the kitchen fire suppression system was completed on March 6, 2024, and was overdue for another inspection by the end of September 2024. Additionally, the facility lacked documentation for the required monthly visual inspections of the kitchen fire suppression system. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Supervisor.
Plan Of Correction
1. No Residents were found to have been affected by the deficient practice. On 12-23-24, the Director of Maintenance performed the required monthly visual inspection. 2. All Residents have the potential to be affected by the deficient practice. 3. The Director of Maintenance was educated on regulation K0324 by the Administrator. The Administrator added the monthly kitchen fire suppression visual inspection to the list of tasks in TELS, a software which schedules and tracks maintenance tasks. The Administrator contacted two new vendors to schedule the biannual kitchen fire suppression system. 4. The Administrator will receive weekly emails from TELS updating the status of the monthly visual inspection for monitoring purposes.
Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining corridor doors, as observed during a survey on December 23, 2024. Specifically, there was a hole above the door knob to the medication room, which compromises the door's ability to resist the passage of smoke. Additionally, the door to room C132, which is equipped with a door closer, failed to self-latch when tested. These issues were identified in two of the seven smoke compartments within the facility. The deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Supervisor on the same day. The failure to maintain the integrity of corridor doors as required by NFPA 101 and CMS regulations indicates a lapse in ensuring that doors resist the passage of smoke and maintain proper latching mechanisms. This oversight affects the safety and compliance of the facility's smoke compartments.
Plan Of Correction
1. No Residents were found to have been harmed by the deficient practice. On 12-30-24, the Director of Maintenance completed repairs on the hole in the Medication Room door, and the hinge keeping room C132 from latching properly. 2. All Residents have the potential to be harmed by the deficient practice. 3. The Director of Maintenance was educated on regulation K 0363 by the Administrator. The Administrator, or designee, will perform weekly rounds with the Director of Maintenance, or designee, to check for compliance. 4. The Administrator will receive weekly emails from TELS, a software which schedules and tracks maintenance tasks, updating the status of the monthly visual inspection for monitoring purposes.
Failure to Follow Pre-Approved Menu and Recipes
Penalty
Summary
The facility failed to adhere to its pre-approved planned menu and recipes for a lunch meal on December 19, 2024. The posted menu indicated that residents were to receive chicken vegetable stew, spaghetti noodles, dinner roll, pineapple tidbits with cream, two-percent milk, coffee/tea, and margarine. However, during the lunch tray delivery, it was observed that the residents did not receive the dinner roll or margarine, and the pineapple tidbits were served without cream. Additionally, the chicken vegetable stew served did not contain several ingredients listed in the facility's recipe card, including chopped ham, lima beans, crushed tomatoes, diced celery, and minced garlic. Interviews with the Dietary Manager and another staff member revealed that the missing cream was due to a delay in the supply truck's arrival, and the staff attempted to make the stew as hearty as possible with the available ingredients. There was no documented evidence that the changes in the menu were discussed with the resident council president, indicating a lack of communication and planning to address the shortfall in ingredients. This failure to follow the planned menu and recipes constitutes a deficiency in meeting the nutritional needs of the residents as required by the facility's dietary services regulations.
Plan Of Correction
1. There were no ill effects noted to residents in the facility due to menu change. 2. Dietary Manager educated on regulation of the notification to residents of menu changes. 3. Dietician or designee will audit to ensure lunch meal is accurate to communicated menu weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital and the reasons for hospitalization for six residents. Resident 9 experienced a large emesis and acute abdominal pain, leading to hospitalization for a urinary tract infection and small bowel obstruction. Resident 28 was transferred to the hospital and admitted with a heart attack. Resident 36 was hospitalized with a urinary tract infection, and Resident 37 was admitted with altered mental status. Resident 43 was sent to the hospital following a fall and complaints of left hip pain, and Resident 62 was admitted with status epilepticus. In all these cases, there was no documented evidence that written notices were provided to the residents' representatives. The Director of Nursing confirmed that the facility did not provide the required written notices to the residents and/or their representatives when the residents were transferred to the hospital. This failure to notify is a violation of the residents' rights as outlined in the facility's discharge policy and resident rights regulations. The lack of documentation and communication regarding the transfers and reasons for hospitalization represents a significant deficiency in the facility's compliance with regulatory requirements.
Plan Of Correction
1. Resident 9, 28, 36, 37, 43 and 62 were notified of transfer to out to hospital by phone; however, they were not notified in writing. 2. Facility reviewed regulation for notice of requirements before transfer/discharge of a resident. Facility put in place utilizing a form to meet the regulation to accompany the bed hold notice. Business Office Manager and Registered Nurse Supervisor's were educated on sending written notice of resident transfer/discharge to responsible party. 3. Social Service director or designee will complete audit to ensure written transfer/discharge notice is sent for hospital transfer weekly times two weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Clarify Physician Orders for Three Residents
Penalty
Summary
The facility failed to clarify a questionable physician's order for three residents, leading to deficiencies in care. For one resident, there was an order to flush a feeding tube with water before and after administering medications, despite the resident no longer receiving medications through the tube. Interviews with the resident and staff confirmed that the feeding tube was not in use for medication administration, yet there was no documented evidence that the physician was contacted to clarify the order. Another resident, who was cognitively intact and had diabetes, had a physician's order to receive insulin at specific times. However, the resident did not receive the insulin on multiple occasions as the staff held the medication based on outdated orders. The Assistant Director of Nursing confirmed that the insulin should not have been held without clarifying the new orders with the physician. A third resident, also cognitively intact, had orders to receive Midodrine for low blood pressure under specific conditions. The medication was administered when the resident's systolic blood pressure was between 90 and 120 mmHg, a range not covered by the existing order. The Assistant Director of Nursing confirmed that the order should have been clarified with the physician to address this gap.
Plan Of Correction
1. Resident 19, 63, 76's orders were clarified with the medical director. 2. Review of residents with tube feed flush order, midodrine hold parameter and insulin hold parameter's were reviewed. Registered Nurse's were educated on clarification of flush orders when tube feeding is discontinued and clarification of hold parameters when therapeutic interchange is made and to review midodrine hold parameters for accuracy. 3. Assistant Director of Nursing or designee will audit three residents with tube feed flush order, midodrine order or insulin with hold parameters weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Follow Protocols for Neurological Checks and Medication Administration
Penalty
Summary
The facility failed to adhere to its protocol for completing neurological checks following a fall for one resident. This resident, who was moderately cognitively impaired and had diagnoses including peripheral vascular disease and atrial fibrillation, was found on the floor without injury. However, later that day, the resident exhibited symptoms such as right-sided weakness, mouth drooping, and confusion. Although a neurological assessment form was initiated, the assessments were not completed according to the facility's protocol, which required checks every 15 minutes for one hour, every hour for four hours, and every four hours for 19 hours. Additionally, the facility did not administer medications as ordered by the physician for another resident. This resident, who was cognitively intact and had diagnoses of heart failure and hypotension, was prescribed Midodrine to be administered with meals on specific days, provided their systolic blood pressure was below 120 mmHg. Despite this, the medication was administered on several occasions when the resident's systolic blood pressure exceeded 120 mmHg. The Assistant Director of Nursing confirmed that the neurological assessments and medication administration were not conducted as per the facility's protocols.
Plan Of Correction
1. Resident 37 did not have documented neurological assessments (neurochecks) fully completed prior to transfer to hospital. Medication error completed on resident 76, hold parameter clarified, resident notified and Medical Director notified. There were no ill effects to resident 76. 2. Licensed Staff educated on completion of neurochecks and following hold parameters for midodrine. 3. Director of Nursing or designee will review neurochecks for completion weekly times four weeks and monthly times two months. Director of Nursing or designee will audit residents with midodrine hold parameters weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for two residents. For one resident, a quarterly Minimum Data Set (MDS) assessment revealed that the resident was cognitively intact, required assistance with care needs, and received opioid medication for chronic pain syndrome. Physician's orders indicated the resident was to receive 10 mg of Oxycodone every six hours as needed. However, an investigation found that 60 tablets of Oxycodone were unaccounted for after being delivered, with only one of the two cards of medication located. For another resident, the MDS assessment showed moderate cognitive impairment, continuous pain, and the use of opioid medication for polyneuropathy. Physician's orders specified 5 mg of Oxycodone every eight hours. An investigation revealed that 60 tablets of Oxycodone were missing, with only one card of medication found from a delivery of 88 tablets. The Director of Nursing confirmed the facility's inability to locate the missing medications for both residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident 19, who had a Stage 4 pressure ulcer and was on Enhanced Barrier Precautions (EBP), a Licensed Practical Nurse (LPN) did not apply a gown during wound care, contrary to the facility's policy and the resident's care plan. The LPN incorrectly assumed that EBP was no longer necessary due to the discontinuation of the resident's feeding tube, which was not aligned with the guidelines for residents with wounds. Resident 62, who required extensive assistance and had skin integrity issues, was also subject to improper infection control practices. During wound care, the LPN failed to remove gloves and perform hand hygiene after completing the wound care and before touching the resident's oxygen equipment and bedding. This action was against the facility's policy, which mandates hand hygiene between tasks to prevent cross-contamination. Additionally, during medication administration for Residents 45 and 47, another LPN handled medications with bare hands and did not perform hand hygiene between residents. This practice violated the facility's policy requiring gloves when handling medications and hand hygiene between residents. Furthermore, Resident 76, who had a dialysis catheter, did not have appropriate signage for EBP until a day after it was ordered, indicating a lapse in implementing necessary infection control measures.
Plan Of Correction
1. Residents 19, 45, 47, 62 and 76 had no ill effects. Resident 76's enhanced barrier precautions were added. 2. Review of residents with central venous catheters were reviewed to ensure enhanced barrier precautions were reviewed and ensured to have enhanced barrier precautions were in place. Licensed Staff educated on following enhanced barrier precautions, hand washing following a treatment and not touching medications with bare hands. 3. Assistant Director of Nursing or designee will audit residents with central venous catheters have enhanced barrier precautions in place weekly times four weeks and monthly times two months. Registered Nurse Assessment Coordinator or designee will audit that enhanced barrier precautions during wound care and hand washing following wound care is being completed weekly times four weeks and monthly times two months. Admissions Director or designee will audit to ensure medications are not being touched with bare hands weekly times four weeks and monthly times two weeks. 4. The Quality Assurance Performance Improvement committee will review previous survey/complaint deficiencies to ensure compliance.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring the call bell was within reach. The facility's policy, dated November 21, 2024, mandates that call bells should be accessible to residents. A quarterly Minimum Data Set (MDS) assessment for the resident, dated November 6, 2024, indicated cognitive impairment and dependency on staff for all care needs, with a care plan specifying that the call bell should be within reach due to decreased mobility. On December 16, 2024, at 10:15 a.m., the resident was observed lying in bed, asking for the call bell, which was found in the nightstand drawer, out of reach. A nurse aide confirmed that the resident could use the call bell and it should have been accessible. The Director of Nursing also confirmed that the call bell should have been within reach.
Plan Of Correction
1. Resident number 2's call bell was placed within reach. 2. Staff rounded in facility to ensure resident call bells were within reach. If found, resident call bells were placed within reach. Education provided to nursing staff to ensure call bells are within resident's reach. 3. Director of Nursing or designee will complete audit to ensure resident's call bells are within reach weekly times two weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their responsible parties about the bed-hold policy upon transfer to the hospital for three residents. Resident 9 was transferred to the hospital with a large emesis, acute abdominal pain, and a history of bowel obstruction, and was admitted with a urinary tract infection and small bowel obstruction. Resident 37 was found on the floor with no injuries but was transferred to the hospital and admitted with altered mental status. Resident 43 experienced a fall and complained of left hip pain, leading to a hospital transfer and admission. In all these cases, there was no documented evidence that the residents or their responsible parties were informed about the facility's bed-hold policy at the time of transfer. The Director of Nursing confirmed the lack of documentation regarding bed-hold notifications for these residents. The issue was identified by the new Business Office Manager on September 9, 2024, indicating a lapse in the facility's protocol to inform residents or their representatives about the bed-hold policy during hospital transfers. This deficiency was cited as past noncompliance, highlighting a failure in communication and documentation processes within the facility.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of their medical conditions and treatments. For one resident, the MDS assessment incorrectly indicated that the resident received injections during the assessment period, despite no documented evidence of such injections. Additionally, the assessment failed to note the presence of a nephrostomy tube, which was consistently treated as per physician's orders. Another resident's MDS assessment did not reflect the administration of insulin injections, which were documented in the Medication Administration Records (MARs), and incorrectly indicated the receipt of antibiotics, which were not administered. Further inaccuracies were found in the MDS assessments of two other residents. One resident's assessment failed to document the application of an antibiotic ointment to a diabetic ulcer, despite treatment records confirming its use. Another resident's assessment inaccurately coded the receipt of antipsychotic medication, despite consistent administration as per physician's orders. These errors were confirmed through interviews with facility staff, including the Assistant Director of Nursing and the Registered Nurse Assessment Coordinator, highlighting a failure in accurately coding and documenting resident assessments.
Plan Of Correction
1. Resident 35, 36, 48 and 60's current Minimum Data Set (MDS) assessments are accurate. Facility was unable to correct past MDS due to them being closed. 2. Review of residents with nephrostomy tubes, antibiotic ointment, insulin injections and antipsychotic medications were reviewed for accuracy. Registered Nurse Assessment Coordinator was educated on ensuring accuracy of the MDS coding with current orders. 3. Registered Nurse Assessment Coordinator or designee will audit three residents with nephrostomy tube, antibiotic ointment, insulin injections or antipsychotic medications weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans to reflect changes in residents' care needs for four residents. Resident 28, who was cognitively impaired and required dialysis, had a care plan indicating the use of a fistula for dialysis. However, observations revealed the use of a Central Venous Catheter instead, and the care plan was not updated to reflect this change. The Director of Nursing confirmed the oversight. Resident 33, who was cognitively intact and had a diagnosis of multi-drug resistant organisms, was initially on contact precautions due to ESBL - E. coli. Physician's orders later indicated that the resident was no longer on contact precautions, but the care plan was not updated to reflect this change. The Assistant Director of Nursing/Infection Preventionist confirmed that the care plan should have been updated. Resident 39, who was cognitively impaired and had no pressure injuries, was on Enhanced Barrier Precautions due to a chronic wound. Observations showed that the resident's pressure ulcers had resolved, but the care plan was not updated to reflect this. Similarly, Resident 68, who had a reopened Stage 3 pressure injury, did not have an updated care plan to include this condition. The Director of Nursing confirmed the care plan was not revised for Resident 68.
Plan Of Correction
1. Resident 28, 33, 39 and 68's care plans were updated. 2. Review of residents with central venous catheter, resolution of contact isolation, resolution of enhanced barrier precautions due to skin breakdown and new pressure ulcers were reviewed to ensure care plans were accurate. Registered Nurse Assessment Coordinator's were educated on ensuring timely updating of resident care plans is being completed. 3. Registered Nurse Assessment Coordinator or designee will audit three residents care plan with a central venous catheter, resolution of contact isolation, resolution of enhanced barrier precautions due to skin breakdown and new pressure ulcers weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for one resident, identified as Resident 19, by not following the physician's orders for wound treatment. Resident 19 had a Stage 4 pressure ulcer on the left heel and a non-stageable pressure ulcer at another site. The care plan indicated an actual skin breakdown on the resident's left great toe, requiring specific treatment as per physician's orders. These orders included cleansing the wound with Acetic Acid 0.25 percent, applying medical grade honey, and then applying Calcium Alginate before securing with gauze and paper tape. On December 16, 2024, during an observation of wound care, it was noted that the LPN did not apply the medical grade honey and Calcium Alginate as ordered. Instead, the LPN only cleansed the wound with Acetic Acid and applied a dressing soaked in the same solution, followed by a dry gauze and paper tape. This deviation from the prescribed treatment was confirmed through interviews with the LPN and the Assistant Director of Nursing/Infection Control Preventionist, indicating a failure to adhere to the physician's orders for wound care.
Plan Of Correction
1. Resident 19's treatment was properly completed per physician order. Licensed Practical Nurse was educated on following physician treatment orders. 2. Licensed Staff educated on following physician treatment orders. 3. Registered Nurse Assessment Coordinator or designee will audit three treatments weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Flush IV Catheter as per Policy
Penalty
Summary
The facility failed to ensure proper flushing of an intravenous line for a resident, as required by their policy. The policy, dated November 21, 2024, mandates that midline and central line intravenous catheters be flushed to maintain patency, prevent mixing of incompatible medications, and ensure the complete administration of medication. The policy specifies using the SASH method (saline, administer medication, saline, heparin) for intermittent treatments. For Resident 10, physician's orders dated November 14, 2024, required staff to flush the peripherally inserted central catheter (PICC) with 10 ml of 0.9 percent Normal Saline every shift to maintain intravenous line patency. Despite these orders, the Medication Administration Records (MARs) for November 2024 showed that staff administered one gram of Ertapenem Sodium intravenously every day at 9:00 a.m. from November 15 through 24, 2024, without documented evidence of flushing the catheter before or after medication administration. This was confirmed in an interview with the Director of Nursing and Assistant Director of Nursing on December 18, 2024, who acknowledged the lack of documentation for flushing the IV catheter according to the facility's policy.
Plan Of Correction
1. Resident 10's intravenous (IV) flush orders, before and after medications, were clarified with the Medical Director. Resident 10 had no ill effects. 2. Residents with IV flush orders were reviewed for accuracy. Registered Nurses were educated on clarifying before and after medication administration flush orders for IVs. 3. Director of Nursing or designee will audit residents with IV orders to ensure they include flush orders for before and after medication administration weekly times four and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several deficiencies observed during a survey. In the B-wing medication cart, multi-dose containers of inhalers for a resident were not labeled with the date they were opened, contrary to the manufacturer's instructions. Additionally, an insulin pen for another resident, which was no longer prescribed, was not discarded as required. These lapses were confirmed by a Licensed Practical Nurse during the survey. Further deficiencies were noted in the medication room and C-wing medication cart. The medication refrigerator's temperature was not consistently monitored and documented on the night shift, with only six recorded checks over a 17-day period. This was confirmed by a Registered Nurse. Additionally, loose medications were found in the C-wing medication cart, indicating improper securing of medications. These findings were corroborated by interviews with nursing staff and the Assistant Director of Nursing, who acknowledged the lapses in medication management and storage.
Plan Of Correction
1. Resident 2's inhaler was discarded due to being opened without being dated. Resident 63's insulin pen was discarded due to being discontinued. Medication room fridge temperature was checked and marked to be within appropriate level at time of review. Medication carts were checked and loose pills removed. 2. Medication carts were checked for inhalers and insulin pens for date and active order. Licensed Staff educated on dating open inhalers, discarding discontinued insulin pens, completing daily medication room fridge temperature and removing loose pills from medication carts. 3. Admissions Director, who is a licensed staff member, or designee will audit medication carts for undated inhalers or discontinued insulin pens weekly times four weeks and monthly times two months. Admissions Director or designee will audit medication carts to ensure no loose pills in the cart weekly times four weeks and monthly times two months. Assistant Director of Nursing or designee will audit medication room fridge temperature log for completion weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Recurring Deficiencies in Quality of Care and Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of the current survey ending December 19, 2024. The survey identified repeated deficiencies in areas such as quality of care, specifically in following physician's orders, treatment of pressure ulcers, medication storage and labeling, and infection control practices. These deficiencies were previously cited in a survey ending January 11, 2024, and the facility had developed plans of correction that included audits and reporting to the QAPI committee. However, the current survey revealed that these plans were not successfully implemented, leading to ongoing non-compliance. The specific deficiencies included failure to follow physician's orders, inadequate treatment of pressure ulcers, improper storage and labeling of medications, and non-compliance with infection control practices. Despite the facility's plans to conduct audits and review results with the QAPI committee, these measures were ineffective in maintaining compliance with the relevant regulations. The repeated nature of these deficiencies indicates a systemic issue within the facility's quality assurance processes.
Plan Of Correction
1. The Quality Assurance and Performance Improvement committee reviewed current survey deficiencies and plan of correction including audits. 2. The Quality Assurance and Performance Improvement committee reviewed previous survey/complaint deficiencies to correct deficiencies and ensure that plans to effectively address recurring deficiencies. 3. The Quality Assurance and Performance Improvement committee was educated on the Quality Assurance and Performance Improvement Plan. 4. The Quality Assurance Performance Improvement committee will review previous survey/complaint deficiencies to ensure compliance.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2024. The regulation requires a minimum of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. The deficiency was identified through a review of nursing schedules and staffing information, which revealed that the facility did not meet these staffing ratios for several days across different shifts in November and December 2024. Specifically, the facility was found to be understaffed on the day shift for seven out of 21 days, on the evening shift for six out of 21 days, and on the overnight shift for 14 out of 21 days. For instance, on November 17, 2024, the facility had a census of 80 residents, requiring 8.00 NAs during the day shift, but only 7.45 NAs were available. Similar discrepancies were noted on other days, with the number of NAs falling short of the required numbers based on the facility's census data. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the required staffing ratios on the specified days. No additional higher-level staff were available to compensate for these deficiencies, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. 2. The facility will continue to take measures to adequately provide staff to meet the required Certified Nursing Assistant to resident ratios. When total certified nursing assistant to resident ratios is unable to be met, the facility will reevaluate the scheduling of new admissions. The Nursing Home Administrator or designee will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios. 3. The Nursing Home Administrator or designee will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months. 4. The results will be reviewed at Quality Assurance Performance Improvement meetings until substantial compliance has been met.
LPN Staffing Deficiencies in November and December 2024
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on specific days in November and December 2024. On November 17, 2024, the facility had a census of 80 residents, necessitating 2.00 LPNs during the day shift, but only 1.91 LPNs were available. Similarly, on November 23, 2024, with a census of 79 residents, 1.98 LPNs were required, yet only 1.47 LPNs were present. This indicates a shortfall in staffing levels during the day shift on these dates. Additionally, the facility did not meet the required staffing ratios during the overnight shift on December 17 and 18, 2024. On December 17, with a census of 82 residents, 2.05 LPNs were needed, but only 2.03 LPNs were available. On December 18, with a census of 81 residents, 2.03 LPNs were required, but only 2.00 LPNs were present. The Nursing Home Administrator confirmed these deficiencies, and no additional higher-level staff were available to compensate for the shortfall.
Plan Of Correction
1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. 2. The facility will continue to take measures to adequately provide staff to meet the required Licensed Practical Nurses to resident ratios on all shifts. When total Licensed Practical Nurses to resident ratios is unable to be met, the facility will reevaluate the scheduling of new admissions. The Nursing Home Administrator or designee will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios. 3. The Nursing Home Administrator or designee will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months. 4. The results will be reviewed at Quality Assurance Performance Improvement meetings until substantial compliance has been met.
Failure to Notify Resident's Representative of Hospital Transfer and Medication Changes
Penalty
Summary
The facility failed to ensure proper notification of a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the facility did not inform the resident's representative about the resident's transfer to the hospital on November 9, 2024, after the resident exhibited altered behavior and was diagnosed with status epilepticus. Additionally, there was no documented evidence that the resident or their representative was notified about changes in medication orders, including the administration of Keppra and Pantoprazole, on November 24 and November 26, 2024, respectively. The resident in question had moderate cognitive impairment and required assistance with daily care needs, with diagnoses including epilepsy and a gastrointestinal stromal tumor. The Director of Nursing confirmed that the notifications were not made, which is a violation of the facility's policy on residents' rights. This policy mandates immediate notification of the resident, consultation with the resident's physician, and notification of the resident's representative when there is a significant alteration in treatment or a decision to transfer the resident from the facility.
Plan Of Correction
1. Resident 1 was notified of changes, and it was documented in point click care which is an electronic medical record keeping system utilized by the nursing home. 2. Education to licensed staff including agency to be completed on notification and documentation. 3. Audits will be conducted daily X 5, then weekly X 4 until compliance is met. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Accommodate Resident Toileting Preferences During Meals
Penalty
Summary
The facility failed to reasonably accommodate the toileting preferences of two residents, leading to a deficiency in resident care. Resident 1, who has a diagnosis of Malignant Carcinoid Tumor of the Stomach and experiences frequent bowel incontinence, reported that she is not toileted during meals due to an infection control policy. This policy prevents staff from assisting residents with toileting until after meal trays are distributed and collected. As a result, Resident 1 often becomes incontinent during mealtimes, which she finds distressing and inappropriate given her medical condition. Similarly, Resident 2, who is cognitively intact and suffers from frequent urinary tract infections, expressed that she is unable to use the bathroom during meal service, sometimes waiting up to an hour. This resident uses a bedpan when in bed and a toilet with assistance when in a wheelchair. Staff interviews confirmed that they were instructed not to toilet residents during meals for infection control reasons. The Director of Nursing and the Nursing Home Administrator acknowledged the policy but stated that toileting needs during meals would be addressed on a case-by-case basis, although this was not reflected in the residents' experiences.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 193 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Johnstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia At Arbutus Park | 2.4 mi | ★★★★★ | 14 | 0 |
| Windber Woods Senior Living & Rehabilitation Ctr | 2.5 mi | ★★★★★ | 16 | 0 |
| Laurel View Village | 4.3 mi | ★★★★★ | 7 | 0 |
| Conemaugh Memorial Medical Center Tcu | 5.8 mi | ★★★★★ | 2 | 0 |
| Quality Life Services - Westmont | 6.3 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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