Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgeview Healthcare & Rehab Center during CMS and state inspections, most recent first.
Failure to Consistently Apply Ordered TED Compression Stockings: The facility did not consistently follow physician orders for TED stockings for two residents with dementia and venous insufficiency. Staff failed to document or ensure application of the stockings, and observations confirmed both residents were not wearing them despite TAR entries indicating they had been applied. The DON confirmed the orders were not consistently implemented.
The facility failed to involve residents in decisions about how resident activity fundraising funds were used. Resident council minutes did not show that resident views or recommendations were considered, and account details such as debits, credits, and balances were not reviewed with the council. During a resident group interview, residents said they were not given the chance to discuss how the funds were spent or informed of the account balance, and the NHA could not provide documentation showing resident input was obtained.
A resident admitted with adjustment disorder and Alzheimer’s disease had a history of suicidal ideation documented in the PASRR and a nurse note after a 70-day hospitalization. The baseline care plan did not include individualized interventions, monitoring considerations, or care approaches to address the resident’s immediate safety needs related to that history, and the NHA and DON could not provide documentation that the plan addressed it.
A resident with dementia and depression lost an upper denture, and the diet was changed to mechanical soft after the denture went missing. The resident's representative said nursing staff were told when the denture was first noticed missing, and the dentist required consent forms and prepayment before replacement could be scheduled. The record did not show that the care plan was updated to address the missing denture, diet change, dental eval, chewing ability, nutrition needs, or oral health.
Opened multi-dose Aplisol vials were found undated in the medication refrigerators in two medication rooms. An LPN and an RN both confirmed the vials had been opened without being dated, and the DON acknowledged the facility did not follow acceptable storage and labeling practices for multi-dose meds.
Delayed Dental Services for Lost Denture: A resident with dementia and severe cognitive impairment lost an upper denture, and the family representative reported the issue to nursing. Although the facility policy called for prompt referral for lost dentures, the dental service was delayed because required consent and prepayment had not been completed, leaving the resident without the needed replacement denture.
Incomplete and inaccurate clinical documentation was found for two residents. One resident with dementia had a body audit showing no skin alterations, followed later the same day by nursing notes documenting bruising to both upper extremities and then the left shoulder, without measurements, description, or resolution details. Another resident with heart failure had an order for IV ampicillin-sulbactam for cholecystitis, but the MAR did not document administration at two scheduled times, even though the NHA and DON stated it was given as ordered.
Failure to Implement Ordered Neutropenic Precautions: A resident with rectal cancer receiving capecitabine had physician-ordered neutropenic precautions, but the room displayed EBP signage instead. A nurse aide entered the room without hand hygiene, a face mask, or protective garments, and did not clean hands on exit. The care plan lacked resident-specific neutropenic interventions, and the ADON could not provide evidence of staff training on the precautions.
The facility failed to maintain an effective training program to ensure LPNs had documented competency in central line management before administering IV antibiotics through a resident’s tunneled central line. A resident with heart failure and a central line to the right subclavian vein received ampicillin-sulbactam via the line on multiple occasions, but the RNC, NHA, and DON could not provide evidence of initial or annual competency validation for central line care, and the annual skills review did not include this training.
Delayed Response to Resident Incontinence Care Request: A cognitively intact resident with morbid obesity, IBS, and a care plan for bowel/bladder incontinence rang for help needing to be changed, but an LPN deferred care during tray pass and staff waited to complete meal service first. The resident reported she had to wait until after lunch to receive incontinence care, and the assistance was not provided until about an hour after the initial call bell request.
A resident with chronic pain syndrome had Tramadol orders for both scheduled and PRN use, but the controlled substance logs did not match the MAR. The log for one Tramadol dose strength stopped accounting for doses while the MAR showed multiple administrations, and the log for the other strength showed removals that were not documented on the MAR. The NHA and DON were unable to reconcile the discrepancies between the controlled substance records and the MAR.
The facility failed to keep a surety bond large enough to cover resident funds managed by the facility. Review of the resident fund account showed balances above the $200,000 bond amount, and the RNC could not provide documented evidence of a bond covering those balances.
Inaccurate PBJ Staffing Submission: Facility records showed RN and licensed nursing coverage was present, but PBJ reports triggered for no RN hours and no 24-hour licensed nursing coverage on multiple days. The NHA stated the facility changed reporting systems and a lapse in data transmission occurred during the transition, resulting in staffing information not being accurately transmitted to PBJ.
Surveyors found that the facility failed to keep the environment free of accident hazards by leaving unsecured medications and medicated creams accessible in resident rooms. A cognitively intact resident approved for self-administration had an oral muscle relaxant pill left on a bedside table, and additional anticoagulant and antidepressant pills were found on the floor in another room. Another cognitively intact resident had an unlabeled hydrocortisone cream at the bedside with no physician order, and a third cognitively intact resident had zinc oxide ointment routinely left at the bedside, despite not being formally approved to self-administer. Staff, including LPNs and an RN supervisor, acknowledged that these medications and products should not have been left accessible, contrary to facility policies on medication administration and self-administration.
Untimely response to resident requests for assistance: Several residents reported long waits after using the call bell, including waits of 30 minutes to 2 hours for help with toileting, cleaning up, transfers, and returning to bed after dialysis. A resident representative also reported that a resident was left weak and disoriented after dialysis and then waited 45 minutes to an hour for staff response. The NHA and DON acknowledged the expectation for dignified care, but no explanation was provided for the delays.
Failure to Timely Notify Resident Representative of Hospital Transfer After Fall: A resident with severe cognitive impairment, cerebral infarction, and ESRD fell from his wheelchair, sustained head abrasions, and was sent by EMS to the ED for evaluation after staff notified the physician. The resident’s representative said she was not informed until the next day, despite providing an updated phone number and there being a secondary emergency contact; the NHA and DON could not provide evidence of timely notification.
A resident with moderate cognitive impairment and diagnoses including surgical aftercare and a chronic foot ulcer received PRN alprazolam multiple times for anxiety. The record did not show documented behavioral symptoms or medical justification for several doses, and there was no documentation that staff tried non-pharmacological interventions before administering the medication. The MDS also showed no behavioral, verbal, or physical symptoms during the assessment period, and the DON could not provide documentation supporting the PRN use.
A resident’s quarterly MDS incorrectly recorded seven insulin injections during the 7-day look-back period, even though the MAR showed no documented insulin administration. The NHA confirmed the resident did not receive insulin injections as documented on the MDS.
A resident with anoxic brain damage and moderate cognitive impairment had repeated vaping-related behavior, including attempting to vape during transport and previously possessing vaping materials hidden on her person. Staff and the NHA acknowledged the resident had access to vaping supplies from a visitor, but the comprehensive care plan did not address the resident’s vaping preference or behavior, and it lacked measurable goals, supervision, safety precautions, or psychosocial supports tied to the resident’s expressed needs and facility policy.
Failure to Provide Ordered Humidified Oxygen: A resident with respiratory failure and COPD was ordered oxygen with humidified water at 4 L/min via NC, but staff failed to attach the humidifier bottle. The resident reported a dry nose and said she had told nursing staff about the issue more than a week earlier. An LPN later confirmed the resident was not receiving humidified oxygen, and the NHA acknowledged the facility was responsible for following the MD order.
Expired biologicals were found in the 3rd-floor med room and Central Supply Room. An LPN observed 14 cartons of Glucerna CarbSteady 1.2 Cal available for resident use, with some in the refrigerator and others on the countertop, all past expiration. The NHA also observed expired cases of Glucerna CarbSteady, Two Cal HN, and Vanilla Ensure on supply shelves, while current unexpired biologicals were reportedly available and being delivered to nursing units.
A resident with intact cognition and morbid obesity reported that grievance information and State agency contact details posted near the nursing station were too high to read from her wheelchair. Surveyors observed the required posting in small print above 48 inches and partially blocked by a shredding box, making it difficult for wheelchair users to access the resident rights and complaint information.
Two residents with cognitive impairments and complex medical conditions experienced significant, unaddressed weight loss due to the facility's failure to assess, monitor, and communicate changes in nutritional status. The facility did not follow its own policies for reweighing, notifying appropriate staff, or implementing interventions, and did not adequately evaluate contributing factors such as medication side effects and inconsistent intake.
Two residents had inaccurate MDS assessments: one was incorrectly documented as having received insulin injections during the look-back period, despite no evidence in the medication administration records, and another was not coded as edentulous on the MDS despite clinical records and observations confirming the absence of natural teeth.
A resident with Parkinson's disease and dementia became edentulous after multiple tooth extractions and was in the process of receiving full dentures. However, the facility did not develop or implement a care plan addressing the resident's dental status or outline steps and timelines for obtaining dentures, as confirmed by staff and clinical record review.
A resident with dementia and Parkinson's disease, identified as being at risk for falls, did not have physician-ordered non-skid strips applied to the floor as required. Observations and staff interviews confirmed the absence of these safety measures, indicating staff did not consistently follow the care plan and physician's orders.
The facility did not ensure timely payment for essential goods, services, and staff payroll, resulting in multiple outstanding vendor balances and returned payroll checks for 27 staff members. The NHA confirmed a lack of evidence for payments or formal agreements for overdue invoices, and administration did not have access to verify payment status.
A resident with multiple chronic conditions persistently refused hygiene care, including showers, toileting, and housekeeping, resulting in prolonged exposure to urine and feces and unsanitary room conditions. Staff did not implement alternative infection control strategies or individualized interventions, and the resident's mattress and linens were only replaced when permitted, approximately every three months. Facility leadership confirmed the ongoing unsanitary environment and lack of effective infection prevention measures.
A resident with COPD and dementia, but assessed as cognitively intact, was found with medication left at the bedside without documented assessment or approval for self-administration. Facility policy requires interdisciplinary team determination and documentation for self-administration, which was not completed in this case.
A resident was left in urine and feces-soaked linens that leaked onto the floor, creating a visibly soiled and foul-smelling environment. The unsanitary conditions persisted for several hours without intervention, as confirmed by a registered nurse and acknowledged by the facility administrator.
A resident with multiple health conditions was observed to have a fungal rash that was not assessed, documented, or addressed in the care plan. Staff noted the presence of multiple fungal areas but reported frequent refusals of skin assessments by the resident. There were no physician orders or care plan updates for the fungal rash, and the DON confirmed the lack of documentation and follow-up.
A resident with severe cognitive impairment and a history of falls experienced three falls within a day without additional safety interventions being implemented, despite ongoing confusion and medical instability. Separately, a cognitively intact resident was found with another resident's medications at his bedside after refusing them, and reported frequent medication administration errors. The DON and NHA confirmed that effective safety measures and medication security were not maintained.
The facility did not employ a full-time qualified director of food and nutrition services, as the dietary supervisor lacked required certification and had not completed the necessary program. After the resignation of the full-time RD, the facility relied on a corporate RD who provided only remote services, resulting in no on-site oversight, staff training, or direct observation of residents for nutritional assessments.
A cognitively impaired resident at Ridgeview Healthcare & Rehab Center was sexually abused by another resident, who was cognitively intact. The incident was witnessed by staff, who reported it immediately. The impaired resident, unable to consent due to severe cognitive impairment, was found with her brief removed and appeared distraught. Legal action is being pursued against the perpetrator.
The facility did not meet the required nurse aide to resident ratios on two shifts. On one evening shift, only 6.10 nurse aides were provided instead of the required 8 for a census of 88, failing the 1:11 ratio. On the same night shift, 5.10 nurse aides were provided instead of the required 5.87, failing the 1:15 ratio. No additional higher-level staff were available to compensate for this deficiency.
The facility did not meet the required LPN to resident ratios on three night shifts, failing to provide the minimum LPN staffing levels as per regulation. On three occasions, the number of LPNs was below the required level for the resident census, and no additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed these staffing shortfalls.
The facility did not meet the required minimum of 3.2 hours of direct resident care per day, providing only 2.92 hours on a specific date. This was confirmed by the Nursing Home Administrator.
The facility failed to conduct a comprehensive assessment to determine necessary resources for resident care, lacking details on nurse staffing and activity needs for younger residents and those with mental health diagnoses. The activities program was inadequate, with residents expressing dissatisfaction. The facility relied heavily on agency staff, employing less than half of its required nursing staff.
The facility failed to provide a comprehensive activity program that meets the diverse needs and preferences of its residents, particularly affecting those under 60 and with mental health diagnoses. The activity program lacked variety and engagement, with residents expressing dissatisfaction over used bingo prizes and the absence of activities tailored to their interests. The Activity Director confirmed the lack of a dedicated budget and specific activities for younger or mentally ill residents.
The facility failed to prevent falls for two residents with cognitive impairments due to inadequate supervision and improper equipment use. One resident experienced multiple falls despite being at high risk, while another fell due to unlocked wheelchair brakes. Additionally, a resident reported being burned by fluctuating water temperatures in a shower room, highlighting a failure to maintain a safe environment.
The facility failed to comply with regulations by not ensuring timely payment for essential goods and services, as required by the 28 PA Code. Outstanding balances over 121 days were noted, and the Nursing Home Administrator confirmed the lack of evidence for payments or agreements. This non-compliance risks the health and safety of residents.
A resident reported the theft of his cellphone, identifying two agency nurse aides as alleged perpetrators. The facility failed to report the incident to local law enforcement, the State Licensing Agency, or the Local Area Agency on Aging within the required timeframes. The resident contacted law enforcement independently, leading to a police investigation. The facility's investigation lacked timely notifications and documentation, and a PB-22 form was not completed for the alleged perpetrators.
A facility failed to provide person-centered care for a resident requiring hemodialysis, specifically in managing their AV fistula. The resident's care plan lacked individualized interventions for monitoring, care, maintenance, or emergency management of the AV fistula, despite physician orders specifying dialysis days and care instructions. The DON confirmed the absence of a specific care plan for the AV fistula.
An LPN failed to adhere to infection control practices by administering medications to two residents using her ungloved hand, transferring pills into a plastic cup, and handing them to the residents. Additionally, a capsule was dropped on the medication cart, picked up with an ungloved hand, and given to a resident. The DON confirmed these actions breached infection control standards.
The facility failed to comply with Act 52 infection control requirements, as its policy did not include all necessary elements, such as a multidisciplinary committee. Infections were reported monthly instead of within the required 24-hour timeframe, as confirmed by the Infection Preventionist.
The facility failed to ensure timely payment for essential goods and services, with numerous outstanding balances overdue by more than 121 days. The Nursing Home Administrator confirmed the lack of evidence for payments or agreements, and the administration could not verify the status of these bills, demonstrating non-compliance with regulations.
The facility failed to maintain battery-powered emergency lighting on two floors. Observations revealed that emergency lights on the 3rd floor near a resident room and at the 2nd floor Nurse's station did not illuminate when tested. This was confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain the sprinkler system, affecting two floors. Observations revealed a missing ceiling tile in the 1st floor Therapy Room and gaps around sprinkler escutcheons on the 3rd floor. These deficiencies were confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility did not secure an electrical panel on the first floor, leaving it unlocked and accessible to unauthorized persons. This was observed near the Game Room and confirmed by the Facilities Manager and Facility Administrator.
The facility was found non-compliant with infection prevention regulations due to the absence of a designated Infection Preventionist (IP). The facility's policy did not mention the IP role, and during a survey, it was confirmed that no IP was employed after the previous one left. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of an IP and the incomplete infection prevention and control program.
Failure to Consistently Apply Ordered TED Compression Stockings
Penalty
Summary
The facility failed to provide person-centered care by not consistently following physician orders for TED compression stockings for two residents. Resident 25 had diagnoses of dementia and diabetes, with moderately impaired cognition on the annual MDS. A physician order dated February 12, 2026 directed staff to apply TED stockings in the morning and remove them in the evening for venous insufficiency. The March 2026 TAR did not document application of the stockings on March 17, 2026, and no reason was documented for the omission. Observation on March 17 at 12:00 PM and again on March 18 at 1:05 PM confirmed the resident was not wearing TED stockings, and no stockings were observed in the room. The March 18 TAR documented the stockings as applied at 6:00 AM, which was inconsistent with the observations. Resident 66 had diagnoses of dementia and depression and was severely cognitively impaired with a BIMS score of 5 on the admission MDS. A physician order dated February 12, 2026 directed staff to apply TED compression stockings in the morning and remove them in the evening for venous insufficiency. The resident representative reported on March 17, 2026 that staff did not consistently apply the stockings. Observation on March 17 confirmed the resident was not wearing TED stockings, and the March 2026 TAR did not document application or a reason for non-application that day. Observation on March 18 at 1:10 PM again confirmed the resident was not wearing TED stockings as ordered, while the TAR documented application at 6:00 AM, which was inconsistent with the observation. The DON confirmed the facility did not consistently ensure implementation of the physician orders for both residents.
Resident Council Input Not Considered for Fundraising Funds
Penalty
Summary
The facility failed to ensure residents’ views and recommendations regarding life in the facility were considered, including decisions about the use of resident activity fundraising funds. Review of the Resident Activities Fundraising Account ledger from January 2026 through March 2026 showed fundraising activities on January 9, February 5, March 4, and March 18, 2026, with debits for bingo prizes, dye bottles, and fundraising supplies. However, resident council meeting minutes from December 2025 through February 2026 contained no documented evidence that residents’ views were considered when determining how the fundraising funds were used. There was also no documented evidence that the facility reviewed the resident activities fundraising account information, including debits, credits, or account balances, with the resident council. During a resident group interview on March 18, 2026, five residents stated they were not given the opportunity to express views or make recommendations about how the fundraising funds were spent, were not informed of the account balance, and said the facility did not review the account information during resident group meetings. One resident stated that review of the fundraising account had occurred in the past but had not happened in recent months. The nursing home administrator was unable to provide documentation showing residents were afforded the opportunity to express their views or recommendations regarding the use of the resident activities fundraising funds.
Baseline care plan lacked immediate safety information
Penalty
Summary
The facility failed to include sufficient minimum healthcare information in Resident 74’s baseline care plan to address the resident’s immediate safety needs within 48 hours of admission. Resident 74 was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood and Alzheimer’s disease, and the admission MDS dated March 9, 2026, showed the resident was cognitively intact with a BIMS score of 13. The facility policy titled Care Plans-Baseline stated that a baseline care plan should be developed within 48 hours of admission to meet the resident’s immediate needs and include information such as admission orders, physician’s orders, dietary orders, therapy services, social services, and PASRR recommendations, if applicable. The resident’s PASRR dated March 1, 2026, documented passive death wishes in December 2025, a stated plan that the resident did not want to share, and a report that the resident wanted to harm herself. A nurse progress note dated March 3, 2026, documented that the resident was admitted following a 70-day hospitalization related to suicidal ideation and a spontaneous hip fracture after admission to the hospital. Review of the baseline care plan initiated March 3, 2026, showed it did not include individualized interventions, monitoring considerations, or care approaches to address the resident’s immediate safety needs related to the history of suicidal ideation. During interviews, the NHA and DON were unable to provide documented evidence that the baseline care plan had been developed and implemented to address the resident’s history of suicidal ideation.
Failure to Update Care Plan for Missing Denture and Diet Change
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timetables for Resident 66 after the resident lost an upper denture and the diet was changed from regular texture to mechanical soft. Resident 66 was admitted with diagnoses of dementia and depression and had severe cognitive impairment on the admission MDS, with a BIMS score of 5. The admission assessment did not identify dental concerns, but a nurse's note later documented the diet downgrade due to the missing upper denture and a speech therapy consult was ordered. The resident's secondary representative reported that the upper denture had been missing for about one month and that nursing staff had been told when it was first noticed. A dentist's correspondence stated that replacement required completed consent forms and prepayment before scheduling, and the Nursing Home Administrator confirmed the facility was responsible for replacing the lost denture. The clinical record contained no documented evidence that the comprehensive person-centered care plan was revised to reflect the change in condition, including the missing upper denture, altered diet texture, need for dental evaluation, or interventions related to chewing ability, nutrition needs, or oral health.
Opened Aplisol Vials Were Left Undated in Medication Refrigerators
Penalty
Summary
The facility failed to follow acceptable storage and labeling practices for multi-dose medication vials in the second-floor and third-floor medication rooms. A review of the facility policy titled Medication Labeling and Storage, last reviewed April 15, 2025, stated that opened or accessed multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies a different timeframe. The report also cited the manufacturer’s recommendation for Aplisol, which states that vials in use for more than 30 days should be discarded. During an observation of the second-floor medication room on March 19, 2026, two opened multi-dose vials of Aplisol in the medication refrigerator were found without dates showing when they were initially opened. An LPN confirmed the vials had been opened and not dated, and stated they should have been removed from the refrigerator and discarded. A similar observation in the third-floor medication room found two opened multi-dose vials of Aplisol without opening dates. An RN confirmed the vials had been opened and not dated, and the DON later confirmed the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications.
Delayed Dental Services for Lost Denture
Penalty
Summary
The facility failed to ensure timely and necessary dental services for one Medicaid resident who had lost an upper denture. The resident was admitted with diagnoses of dementia and depression, and the admission MDS showed severe cognitive impairment with a BIMS score of 5 and no dental concerns identified at that time. The facility’s dental policy stated that oral and dental services would be provided for each resident and that residents with lost or damaged dentures would be promptly referred to a dentist. The resident’s secondary representative reported that the upper denture had been missing for about a month and had already notified nursing when it was first noticed missing. A grievance filed by nursing on behalf of the representative documented that the dentures were missing, and the resolution noted that a referral had been made for the dentist to replace them. The dentist later stated that a consent form and prepayment were required before services could be provided. The Administrator confirmed that the facility was responsible for replacing the lost upper denture, but the corporate office had not yet provided the prepayment needed for the dental services to be completed.
Incomplete and Inaccurate Clinical Documentation
Penalty
Summary
The facility failed to ensure clinical records were accurate and complete for two sampled residents. Resident 85 had a diagnosis of dementia, and a significant change MDS dated January 9, 2026, documented a BIMS score of 15, indicating intact cognition. A body audit documented on January 18, 2026, at 8:30 AM stated no skin alterations were observed, but a nurse's note later that morning at 11:35 AM documented that the resident returned from a brief hospital visit with bruising to both upper extremities. The note did not include measurements, color, characteristics, or further description of the bruising. A later note on January 20, 2026, documented bruising to the left shoulder, but again did not include size, appearance, progression, or resolution, and the record did not identify when bruising to the right upper extremity resolved. The DON confirmed the facility could not provide additional documentation explaining the discrepancy between the body audit and the later bruising documentation or clarifying when the bruising occurred, its extent, or when it resolved. Resident 7 was admitted with diagnoses including heart failure. A physician's order dated February 26, 2026, directed ampicillin-sulbactam sodium IV 3 grams every six hours for cholecystitis. Review of the March 2026 MAR showed no documented evidence that the medication was administered as ordered on March 7, 2026, at 6:00 AM and March 14, 2026, at 6:00 AM. During interview, the NHA and DON stated the medication was administered as ordered, but the clinical record did not contain documentation confirming those administrations, leaving the record incomplete and inaccurate regarding the ordered IV antibiotic.
Failure to Implement Ordered Neutropenic Precautions
Penalty
Summary
The facility failed to implement physician-ordered infection control precautions for one resident with rectal cancer who was receiving capecitabine, an oral chemotherapy medication with known potential to cause neutropenia. The resident’s physician orders directed staff to use neutropenic precautions, and the resident’s admission MDS documented a BIMS score of 15, indicating cognitive intactness. However, observation of the resident’s room showed signage for Enhanced Barrier Precautions rather than neutropenic precautions, and the posted signage did not reflect the physician-ordered precautions intended to protect the resident from exposure to infectious organisms. Observation of a nurse aide entering the resident’s room with a meal tray showed the employee did not perform hand hygiene before entering, did not wear a face mask or protective garments, and did not perform hand hygiene when leaving the room. The nurse aide stated being unaware that any resident on the unit required special precautions, including neutropenic precautions. The resident’s care plan did not include resident-specific interventions for neutropenic precautions, and the Assistant DON confirmed the purpose of neutropenic precautions but could not provide evidence that staff received training or education on their implementation. Signage reflecting neutropenic precautions with resident-specific interventions was not posted until after surveyor inquiry.
Failure to Train Staff on Central Line Management
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff to ensure licensed nursing staff had the knowledge, skills, and documented competencies needed to safely care for a resident with a central tunneled line catheter. Resident 7 was admitted with heart failure and had a care plan identifying potential complications related to a central tunneled line to the right subclavian vein. A physician ordered ampicillin-sulbactam 3 grams intravenously over 30 minutes every six hours for cholecystitis, and the March 2026 MAR showed that LPNs administered the medication through the central line on multiple occasions. During interview, the RNC was unable to provide documented evidence that the LPNs who administered the IV medication through the central line had demonstrated competency in central line management before doing so. The RNC also confirmed the annual licensed nursing competency and skills review did not include central line care training, and no initial or annual competency validation for central line management was available through the conclusion of the survey. The NHA and DON were also unable to provide documented evidence that central line management had been developed or implemented in the annual licensed nursing competency and skills reviews.
Delayed Response to Resident Incontinence Care Request
Penalty
Summary
The facility failed to provide care in a manner that promotes and enhances resident dignity and quality of life by not responding in a timely manner to a resident’s request for incontinence assistance. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including morbid obesity and IBS. Her care plan addressed bowel and bladder incontinence, chronic UTIs, and IBS, and directed staff to check for incontinence and change her every two hours and as needed; it also noted she required extensive assistance from two staff members for bed mobility. During observation, the resident rang her call bell at 11:30 AM and stated she needed to be changed. An LPN answered the call bell at 11:43 AM, told the resident, "I'll tell the girls," and left without providing care. The LPN then informed NAs in the hallway that the resident needed to be changed, but staff remained waiting for meal cart delivery and tray pass. A staff member stated the resident had been changed not even a half hour earlier. Tray pass proceeded, including delivery of a meal tray to the resident, and no incontinence care was provided at that time. The resident later stated she waited until after lunch to be changed, and after activating the call bell again at about 12:30 PM, she did not receive incontinence care until approximately 12:35 PM, about one hour and five minutes after the initial call bell activation.
Inaccurate controlled substance records for Tramadol
Penalty
Summary
The facility failed to maintain accurate controlled substance records and to ensure that documentation of controlled medication administration matched the inventory records for one resident receiving Tramadol. The facility policy titled Controlled Substances stated that controlled substance inventory is to be monitored and reconciled, with records maintained for receipt, dispensing, disposition, administration, waste, and return to pharmacy. During review of clinical records, the facility was unable to reconcile discrepancies between the controlled substance logs and the Medication Administration Record (MAR) for Resident 56. Resident 56 was admitted with chronic pain syndrome and had physician orders for Tramadol 50 mg every eight hours as needed for pain rated 7 through 10, and Tramadol 25 mg twice daily for chronic pain. The controlled substance log for Tramadol 25 mg showed the last dose administered on February 14, 2026, but the MAR documented 24 administrations of Tramadol 25 mg between February 15 and February 28, 2026. The controlled substance log did not reflect removal or reconciliation of those doses after February 14, 2026. The controlled substance log for Tramadol 50 mg showed seven removals between February 15 and February 19, 2026, but the February 2026 MAR did not show administration of Tramadol 50 mg on those dates and times. During interview, the NHA and DON were unable to provide a controlled substance record accounting for the Tramadol 25 mg doses after February 14, 2026, and were unable to reconcile the discrepancies between the controlled substance records and the MAR for both Tramadol orders.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to ensure the surety bond amount was sufficient to cover the total resident funds held by the facility. A review of the resident fund checking account from January 2026 through March 2026 showed the aggregate resident account fund managed by the facility was $216,243.06 on February 3, 2026, and $208,438.08 on March 3, 2026. The facility’s surety bond, which had been in place since November 1, 2020, was $200,000.00 and did not cover the resident fund balances on those two dates. During an interview on March 18, 2026, at 1:30 PM, the regional nurse consultant reviewed this information and was unable to provide documented evidence that a surety bond was in place in February 2026 or March 2026 to sufficiently cover facility-managed resident funds.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to ensure accurate submission of direct care staffing information to the PBJ system based on payroll and other verifiable and auditable data. Review of the PBJ Staffing Data Report and CASPER Report 1705D for Q4 2025 showed that the facility’s data triggered for no RN hours on September 24 through September 30, 2025, and for failing to have licensed nursing coverage 24 hours a day on those same dates. Review of staffing time sheets and daily nurse assignment sheets showed that RN staffing was working on each date that triggered no RN hours in the PBJ reports, and that licensed nursing coverage was present 24 hours a day on each date that triggered a deficiency in the PBJ reports. During an interview, the NHA stated the facility transitioned to a different reporting system in September 2025 and that a lapse in data transmission occurred during the transition process. The NHA confirmed that RNs and licensed nurses were working on the identified dates, but the staffing information was not accurately transmitted to the PBJ system.
Unsecured Medications and Topical Agents Left Accessible in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free from accident hazards by allowing unsecured medications to be accessible on two nursing units. Facility policies on administering medications and self-administration of medications require that medications be administered safely, only as prescribed, and that any medications permitted for self-administration be stored securely and not accessible to other residents. The policies also state that if safe storage in the resident’s room is not possible, medications must be stored on a central medication cart or in the medication room. Despite these policies, surveyors observed multiple instances where medications and medicated products were left unsecured in resident rooms. For one resident who was cognitively intact and had been assessed and approved for self-administration, surveyors observed an orange oblong pill partially obscured by papers on the bedside table. The resident stated the pill must have fallen out of her medication cup, and an LPN later identified and secured it as methocarbamol 750 mg, for which there was a current physician’s order. In another room, surveyors observed two pills and a clear medication cup on the floor near a bed. An LPN confirmed the medications should not have been on the floor and secured them. The Nursing Home Administrator later identified these pills as Eliquis 5 mg and sertraline 100 mg. For another cognitively intact resident, surveyors found a tube of hydrocortisone 1% cream at the bedside. The tube lacked instructions for use, dosage information, and labeling, and there was no physician order in the clinical record for this medication. A RN Supervisor confirmed the resident should not have had the hydrocortisone cream at the bedside. For a third cognitively intact resident, surveyors observed a tube of zinc oxide 20% ointment at the bedside, labeled with the resident’s name and room number. The resident reported that staff routinely left the ointment at the bedside for application, that she did not apply it herself but could if she chose to, and that staff routinely left medications at her bedside. The Nursing Home Administrator was informed that medicated creams and ointments were being left at bedsides accessible to residents who had no documented assessment or approval to self-administer medications.
Untimely Response to Resident Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident’s quality of life by not responding timely to residents’ requests for assistance. Clinical record reviews showed Resident 68 was admitted with peripheral vascular disease and was cognitively intact with a BIMS score of 13. Resident 11 was admitted with cerebral infarction and end-stage renal failure and was severely cognitively impaired with a BIMS score of 03. Resident 5 was admitted with morbid obesity and was cognitively intact with a BIMS score of 15. Resident 80 was admitted with cerebral palsy and was cognitively intact with a BIMS score of 14. During interviews, Resident 80 reported waiting about 40 minutes for assistance and up to one and a half hours at times, and said he had raised the issue with social services and the DON without resolution. Resident 11’s representative reported that after dialysis, Resident 11 was weak, disoriented, and uncomfortable and then waited 45 minutes to an hour for staff to respond to the call bell to help him back into bed. Resident 68 reported waiting 30 to 45 minutes for staff to respond when he needed help with cleaning up and transferring to the bathroom. Resident 5 reported waiting 45 minutes to two hours for care after ringing the call bell, on all shifts, and said she had raised the concern in nursing staff and resident group meetings without any action. The NHA and DON acknowledged that residents should be treated with dignity and respect and provided care in a manner that promotes quality of life, but no explanation was provided for the untimely responses.
Failure to Timely Notify Resident Representative of Hospital Transfer After Fall
Penalty
Summary
The facility failed to timely notify Resident 11’s representative of his hospitalization after a fall. Resident 11 was admitted with diagnoses including cerebral infarction and end-stage renal failure, and a quarterly MDS dated September 19, 2025, showed he was severely cognitively impaired with a BIMS score of 03. On June 20, 2025, he was found on the floor in his room lying on his back with his head against the closet door after stating he fell out of his wheelchair while trying to stand. He was alert with periods of confusion and had two new superficial abrasions to the mid-occipital region of his head. The nursing supervisor assessed him, the physician was notified, and an order was placed to send him to the community emergency department by EMS for further evaluation. A progress note documented later that evening stated the physician and resident representative were made aware of the order to send Resident 11 to the emergency department, but this was charted about two and a half hours after he had already been sent. During interview, the resident representative stated she was not notified until the following day and was upset that he was in the emergency department overnight without her knowledge. She also stated she had given the facility an updated phone number two weeks earlier, but it was not recorded, and that a secondary emergency contact was not called. The NHA and DON were unable to provide evidence that timely notification was given to the resident representative.
Unjustified PRN Alprazolam Use Without Documented Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that Resident 53 was free from unnecessary psychotropic medication use and chemical restraint use. Resident 53 was admitted with diagnoses including surgical aftercare and a non-pressure chronic foot ulcer, and a quarterly MDS dated September 22, 2025, identified the resident as moderately cognitively impaired with a BIMS score of 12. The resident’s physician orders included alprazolam 0.5 mg PRN for anxiety, first ordered on September 16, 2025 and then continued on September 17, 2025 for 14 days. The eMAR showed the resident received alprazolam on seven occasions between September 17 and September 30, 2025. For all seven administrations, the clinical record did not document that staff attempted any non-pharmacological interventions before giving the medication. On three of the administrations, the record also lacked documentation of any behavioral symptoms or clinical justification for the alprazolam. The MDS Section E completed by the RAC documented that Resident 53 did not exhibit behavioral, verbal, or physical symptoms during the assessment period of September 16 through September 22, 2025, even though alprazolam was administered twice during that period. The resident’s care plan included psychosocial interventions related to depression and bipolar disorder, and the Activities Evaluation documented interests and language preferences, but the record contained no evidence that these individualized interventions were used before the PRN medication was given. The DON could not provide documentation showing medical justification or evidence that non-pharmacologic interventions were attempted prior to alprazolam use.
Inaccurate MDS Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident out of 19 sampled, Resident 5. The quarterly MDS dated September 8, 2025, documented that the resident received seven insulin injections during the 7-day look-back period in Section N0350. However, review of the resident’s MAR for August 2025 and September 2025 showed no documented evidence that any insulin injections were administered during that look-back period. During an interview on October 1, 2025, at 1:50 PM, the Nursing Home Administrator confirmed that Resident 5 did not receive insulin injections during the 7-day look-back period as recorded on the MDS.
Failure to Address Resident Vaping Behavior in Care Plan
Penalty
Summary
The facility failed to incorporate a resident’s known preference and repeated attempts to vape into the comprehensive care planning process. Resident 1 was admitted with anoxic brain damage and had a BIMS score of 12, indicating moderate cognitive impairment. A social service note documented that the resident attempted to vape while being transported to a medical appointment, and the vaping device was found hidden in her underwear. The resident was educated on facility policy and agreed to give up the device. Interviews with another resident, an RN, and the NHA confirmed that Resident 1 had previously possessed vaping materials, and the NHA stated that a visitor was known to supply the resident with vaping materials. The NHA also stated that the resident’s room was checked for vaping supplies, but could not verify when the most recent check occurred, how often checks were done, or provide documentation. The resident’s comprehensive care plan, current at the time of review, contained no evidence that the resident’s desire and repeated attempts to vape had been assessed or addressed, and it lacked interventions for supervision, safety precautions, psychosocial supports, or measurable goals related to vaping behavior and facility policy.
Failure to Provide Ordered Humidified Oxygen
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to a physician’s order for one resident. Resident 70, who was admitted with respiratory failure and had a diagnosis of COPD, was cognitively intact with a BIMS score of 15 on the annual MDS assessment. A physician’s order directed that the resident receive oxygen with humidified water at 4.0 liters per minute by nasal cannula. During an interview, Resident 70 stated her nose had been very dry because there was no water humidification attached to her oxygen delivery system and said she had notified nursing staff about the concern more than a week earlier. At the time of observation, she was receiving oxygen at 4.0 liters per minute via nasal cannula with no humidifier bottle attached to the oxygen flowmeter. A follow-up observation confirmed the humidifier bottle was still not attached, and an LPN acknowledged that the resident was not receiving humidified oxygen despite the physician’s order. The NHA confirmed it was the facility’s responsibility to ensure oxygen therapy was administered in accordance with the physician’s order.
Expired Biologicals Stored in Medication and Supply Areas
Penalty
Summary
The facility failed to ensure that biologicals were stored within their manufacturer expiration dates in one of two medication storage areas, the third-floor nursing unit. A review of the facility policy on Storage of Medications stated that drugs and biologicals are to be stored safely, securely, and in an orderly manner, and that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed. During observation in the third-floor medication room, fourteen individual cartons of Glucerna CarbSteady 1.2 Cal were available for resident use even though each carton had an expired date. Five cartons were in the refrigerator and nine cartons were on the countertop. In the Central Supply Room, four cases of Glucerna CarbSteady 1.2 Cal, one case of Two Cal HN, and one case of Vanilla Ensure were also observed past expiration. The expired products were identified during surveyor observation, and the NHA and an LPN confirmed the items were expired and that current, unexpired biologicals were available and being delivered to nursing units.
Inaccessible posting of grievance and State agency contact information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups, along with a statement that residents may file a complaint with the State Survey Agency, in a form and manner accessible and understandable to residents and resident representatives on the Nursing 2nd Floor. The required grievance and complaint information was posted near the second-floor nursing station, but it was placed in small print and above 48 inches in height, making it difficult for residents using wheelchairs to read or access. Resident 5, who was admitted with diagnoses including morbid obesity, had a quarterly MDS dated September 8, 2025 showing a BIMS score of 15, indicating intact cognition. During interview, Resident 5 stated she could not access the grievance information across from the second-floor nursing station because it was too high to read or see from her wheelchair, and she could not read the names, addresses, and telephone numbers of the pertinent State agency and advocacy groups. An observation of the area also showed the posted information was obstructed by a shredding box, preventing a person in a wheelchair from moving closer to the posting. The Nursing Home Administrator acknowledged that the postings were arranged in a manner that created obstructed access for residents who used wheelchairs.
Failure to Assess and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to properly assess, evaluate, and monitor the nutritional status of two residents who experienced significant weight loss. For one resident with dementia and COPD, there was a documented pattern of frequent loose stools attributed to medication side effects and rectal prolapse. Despite ongoing documentation of these symptoms and a notable weight loss of 14 pounds (11%) over 90 days, there was no evidence that the physician or nurse practitioner evaluated or addressed the repeated episodes of loose stools, nor were adjustments made to the medication regimen. The resident's meal intake was inconsistent, and although nutritional supplements were provided, the underlying causes of weight loss were not adequately investigated or managed by the clinical team. For another resident with Alzheimer's Disease and adult failure to thrive, a significant weight loss of 19.2 pounds (10.53%) was recorded over a one-month period. The facility did not reweigh the resident within 24 hours as required by policy, nor did they notify the physician, resident representative, or Dining Services Director of the weight loss. There was also no documentation that the resident's nutritional status was reviewed or that any interventions were recommended by the Dining Services Director or other members of the multidisciplinary team. These deficiencies were confirmed through staff interviews and review of facility records, which showed a lack of timely assessment, notification, and intervention in response to significant changes in residents' weights. The facility did not follow its own policies regarding weight monitoring, assessment, and communication, resulting in inadequate evaluation and support for residents experiencing significant weight loss.
Inaccurate MDS Assessments for Medication and Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the quarterly MDS assessment indicated that the resident received an insulin injection during the seven-day look-back period. However, a review of the medication administration records for the relevant months showed no documented evidence that the resident received any insulin injections during that period. This discrepancy was confirmed by the Regional Nurse Consultant and the Registered Nurse Assessment Coordinator during an interview. For another resident, the annual MDS assessment did not accurately reflect the resident's dental status. The resident was observed to be edentulous, and dental consults documented the extraction of teeth and the process of obtaining dentures. Despite this, the MDS assessment did not indicate that the resident was edentulous, as required. The Regional Nurse Consultant confirmed that the MDS assessment was not accurate regarding the resident's dental condition.
Failure to Develop and Implement Comprehensive Dental Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing the dental needs of a resident who was admitted with diagnoses including Parkinson's disease and dementia. The resident became edentulous following the extraction of seven teeth, as documented in a dental consult. Subsequent dental consults indicated the fabrication and trial of full upper and lower dentures, but there was no documentation of the results of the denture trial or a clear plan for obtaining dentures. Despite the resident's significant dental changes and ongoing dental interventions, the clinical record did not contain a care plan reflecting the resident's edentulous status or a timeline and actions for obtaining dentures. Interviews with facility staff confirmed that the resident's comprehensive care plan did not address these dental needs, and it was acknowledged that the facility is responsible for ensuring care plans include all identified problems and necessary services.
Failure to Apply Physician-Ordered Non-Skid Strips for Fall Prevention
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered preventative safety measures for a resident. The resident, who had diagnoses including dementia and Parkinson's disease and was assessed as having moderately impaired cognition, had a physician's order for non-skid strips to be placed on the floor on the door side of the bed due to a history of multiple falls and an identified risk for falls. The resident's care plan also included this intervention. During observations on two separate occasions, it was noted that the non-skid strips were not present on the floor as ordered. This absence was confirmed by a Registered Nurse Supervisor. Further, interviews with the Regional Nurse Consultant and Nursing Home Administrator confirmed that staff had not consistently followed the physician's order for the application of non-skid strips for the resident's safety.
Failure to Ensure Timely Payment for Essential Goods, Services, and Payroll
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. A review of the accounts payable ledger revealed multiple outstanding balances exceeding 121 days past due for essential vendors, including pest management, nurse staffing agencies, food suppliers, medical director services, ambulance services, and utility providers. The Nursing Home Administrator (NHA) confirmed that the facility's owners had not provided evidence of payments or formal payment agreements for these overdue invoices, and facility administration did not have direct access to billing or payment records to verify if any past-due bills had been settled. Additionally, the NHA confirmed that 27 staff members received payroll checks that were returned due to insufficient funds, although the corporate office later reissued the checks and covered associated fees. The failure to pay for critical staffing, food services, medical supplies, and essential utilities was identified as noncompliance with regulations requiring financial solvency to prevent operational disruptions that could jeopardize resident health and safety.
Failure to Implement Infection Control for Resident Refusing Care
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for a resident who required assistance with activities of daily living (ADLs), including toileting, bathing, and bed maintenance. The resident, who had multiple diagnoses such as morbid obesity, respiratory failure, COPD, diabetes, and heart disease, consistently refused hygiene care, including showers, toileting, and perineal care, as well as housekeeping services. Despite these refusals, staff did not develop or implement alternative infection control strategies or individualized behavioral interventions. The resident was observed multiple times sitting in urine- and feces-soaked linens, with bodily fluids leaking onto the floor and a strong foul odor present in the room. The mattress and linens were only replaced when the resident permitted, which occurred approximately every three months. Clinical records and care plans documented persistent refusals of care and noted the resident's behavior as a potential infection risk and skin integrity concern. Staff were directed to offer care every two hours and as needed, but records showed the resident refused all scheduled care and skin assessments over an extended period. Facility leadership confirmed the unsanitary conditions and acknowledged that staff did not know how to address the situation. There was no evidence that the facility maintained a sanitary environment or implemented effective infection prevention and control measures for the resident, resulting in prolonged exposure to urine and feces and an unsanitary living environment.
Failure to Assess and Document Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for one resident. According to facility policy, residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, with this determination documented in the medical record and care plan. However, a review of the clinical record for a resident with diagnoses including COPD and dementia, but who was assessed as cognitively intact, revealed no documentation that the resident had been assessed or approved to self-administer medications. During observation, three red gelcap pills were found on the resident's bedside table, later identified as Docusil oral capsules 100 mg. The DON confirmed that there was no documented evidence supporting the resident's ability to safely self-administer medication and acknowledged that the medication should not have been left at the bedside. This failure to follow policy and ensure proper assessment and documentation led to the deficiency.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping services, resulting in a resident being left in urine and feces-soaked linens that had leaked onto the floor in their room. The floor beneath and around the bed was visibly soiled with brown and yellow liquid, emitting a strong, foul odor that was noticeable from the hallway. This unsanitary condition persisted for over four hours, as confirmed by a subsequent observation with a registered nurse, during which no corrective action had been taken. The Nursing Home Administrator acknowledged the failure to maintain a clean and sanitary environment, which compromised the resident's dignity and well-being.
Failure to Assess, Document, and Care Plan for Fungal Rash
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for one resident with diagnoses including congestive heart failure and morbid obesity. The resident was cognitively intact and receiving wound care for a pressure wound and incontinence-associated dermatitis. Despite documentation of these conditions, an observation revealed the presence of a fungal rash under the resident's left axilla, which was not previously assessed or documented in the clinical record. The resident's care plan did not address this fungal rash, and there were no physician orders for its assessment or treatment. Staff interviews confirmed that the resident had multiple fungal areas, but the resident often refused skin assessments. During an attempted assessment, the resident refused further examination. The Director of Nursing confirmed that there was no documentation of assessment, treatment, or care planning for the fungal rash. This lack of assessment, documentation, and care planning was not in accordance with professional standards and facility policy, as required by state regulations.
Failure to Prevent Falls and Medication Errors
Penalty
Summary
The facility failed to implement effective safety measures and provide sufficient staff supervision to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who had dementia and chronic kidney disease, experienced three falls within a 24-hour period. Despite being identified as high risk for falls and exhibiting confusion, fever, and altered mental status, the clinical record did not show that any additional safety interventions were put in place after each fall. The resident ultimately required one-to-one supervision only after the third fall, just prior to being sent to the emergency department for evaluation and treatment of sepsis and other acute conditions. Additionally, the facility did not maintain a safe environment for three other residents. During an observation, a cognitively intact resident was found with a cup containing five pills on his bedside table, which he stated were not his and had been left there after he refused them days earlier. The resident reported that he was frequently given his roommate's and neighbor's medications by mistake. The medications were later confirmed by the DON to belong to another resident, and the nurse on duty acknowledged that the resident should not have had medications at his bedside. Interviews with the DON and NHA confirmed that the facility did not implement additional or effective safety measures to mitigate the risk of falls for the resident who fell multiple times, and that it is the facility's responsibility to ensure a safe environment free of accident hazards, including preventing medication errors and ensuring proper medication security.
Lack of Qualified Food and Nutrition Services Leadership and On-Site RD Oversight
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services and did not ensure that a registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department. The individual appointed as dietary supervisor did not possess the necessary regulatory qualifications, as she was not a Certified Dietary Manager (CDM) and had not completed the required CDM program, with no clear timeline for certification provided. Additionally, after the resignation of the full-time RD, the facility relied solely on a corporate dietitian who provided services remotely, with all dietary documentation and assessments completed off-site. There was no on-site supervisory oversight, staff training, direct observation of residents for nutritional assessments, or monitoring of meal service by the RD during this period.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
Ridgeview Healthcare & Rehab Center was found to be non-compliant with federal and state regulations regarding the freedom of residents from abuse, neglect, and exploitation. The facility failed to protect a cognitively impaired resident, identified as Resident 2, from sexual abuse by another resident, identified as Resident 3. Resident 2, who suffers from Huntington's Disease and dementia, was unable to consent to or initiate sexual behavior due to severe cognitive impairment. Despite this, Resident 3, who is cognitively intact, engaged in inappropriate sexual conduct with Resident 2, which was witnessed by staff members. The incident occurred when two nurse aides, Employee 2 and Employee 3, entered Resident 2's room and observed Resident 3 performing oral sex on Resident 2. The aides immediately reported the incident to the registered nurse on duty, Employee 1. Resident 2 was found lying on her mattress with her incontinence brief removed, and when asked if someone had hurt her, she moaned "yes." A body audit revealed no physical signs of abuse, but the resident was sent to the hospital for a rape kit examination. The state police were notified, and an investigation was initiated. Interviews with the staff confirmed that Resident 2 could not have removed her brief or initiated the interaction due to her cognitive and physical limitations. Resident 3 admitted to the act but claimed that Resident 2 had initiated the interaction, which was not possible given her condition. Legal records indicate that Resident 3 is facing charges of indecent assault on a person with mental disabilities. The facility's failure to protect Resident 2 from abuse was confirmed by the Nursing Home Administrator during the survey.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. The facility will complete an assessment of current residents to identify residents that are at risk for engaging in or being victimized by sexual aggression. Residents that are identified as being at risk will have their individual care plans reviewed and updated with appropriate interventions. This assessment will be conducted upon admission, quarterly, after any significant change and post resident to resident aggression. 2. The facility will review and revise the current facility Abuse Prevention Policy to ensure compliance with federal and state regulations. 3. Facility will conduct re-education for staff across all departments and disciplines on: the facility abuse and prevention policy, recognizing, preventing and reporting sexual abuse. This re-education will include competency testing of staff. 4. Facility will conduct audits of residents to ensure a sexual aggression assessment has been conducted and appropriate interventions have been care planed. Audits will be conducted weekly x4, then monthly x 4. The facility will also conduct an audit of incidents. The purpose of this audit will be to identify any trends in recurring issues that need to be addressed through additional education and/or policy revisions. This audit will be conducted weekly x4, then monthly x 4. All results will be reported to the QAPI Committee.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two shifts out of 21 reviewed, as determined by a review of nurse staffing records and staff interviews. On January 19, 2025, during the evening shift, the facility provided only 6.10 nurse aides instead of the required 8 for a census of 88 residents, failing to meet the 1:11 ratio. Additionally, on the same date during the night shift, the facility provided 5.10 nurse aides instead of the required 5.87 for the same census, failing to meet the 1:15 ratio. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.
Plan Of Correction
1. Facility cannot retroactively correct the failure to meet the ratio requirements of the Certified Nursing Aides as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the Certified Nursing Aides ratio requirements. 3. Facility is actively recruiting Certified Nurses Aides through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for Certified Nursing Aides. 4. The Administrator will audit the staffing schedules to ensure the appropriate number of Certified Nursing Aides are scheduled to achieve compliance. Audits will occur three times per week for one week; weekly for four weeks and monthly for four weeks. The results of the audits will be submitted to the QA Committee.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three separate night shifts out of 21 reviewed. Specifically, on January 15, 19, and 21, 2025, the facility did not provide the minimum LPN staffing levels required by regulation. On January 15, the facility had 2.20 LPNs instead of the required 2.28 for a census of 91 residents. On January 19, there were 1.33 LPNs instead of the required 2.20 for a census of 88 residents. On January 21, the facility had 2.03 LPNs instead of the required 2.25 for a census of 90 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. Facility cannot retroactively correct the failure to meet the ratio requirements of the LPN's as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the LPN's ratio requirements. 3. Facility is actively recruiting LPN's through outside marketing sources; utilizing outside Nurse Agency to supplement LPN's; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for LPN's. 4. The Administrator will audit the staffing schedules to ensure the appropriate number of LPN's are scheduled to achieve compliance. Audits will occur three times per week for one week; weekly for four weeks and monthly for four weeks. The results of the audits will be submitted to the QA Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. A review of the facility's staffing levels revealed that on January 19, 2025, the facility provided only 2.92 hours of direct care nursing per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 22, 2025, who acknowledged the facility's failure to meet the required nursing care hours consistently.
Plan Of Correction
1. Facility cannot retroactively correct the failure to meet the overall PPD requirements of the nursing staff as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the overall PPD requirements for nursing staff. 3. Facility is actively recruiting Certified Nurses Aides and Licensed Practical Nurses through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides and Licensed Practical Nurses; and daily staffing meetings being conducted in attempts to maintain State Mandated PPD requirements. 4. The Administrator will audit the staffing schedules to ensure the facility is staffed appropriately to reach the mandated State PPD. Audits will occur three times per week for four weeks and weekly for four weeks. The results of the audits will be submitted to the QA Committee.
Inadequate Facility Assessment and Activities Program
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care during both routine operations and emergencies. The assessment provided was not tailored to the specific needs of the residents, lacking detailed information on nurse staffing requirements, including staffing levels, use of agency staff, recruitment and retention plans, and emergency contingency plans. The facility had a census of 90 residents, with 18 under the age of 60 and 80-85 with mental health diagnoses, yet the assessment did not address the specific activity needs of these populations. Additionally, the facility's activities program was inadequate, failing to meet the cognitive, functional, and recreational needs of its residents, particularly the younger residents and those with mental health diagnoses. Residents expressed dissatisfaction with the activities program, noting that Bingo prizes were used items and there was no designated activity budget. The facility relied heavily on agency staff for over 60% of its nursing needs and employed less than half of its required nursing staff, which was confirmed by the Nursing Home Administrator. These deficiencies have the potential to negatively affect the quality of care and quality of life for all residents.
Plan Of Correction
1. Ridgeview Healthcare and Rehabilitation Center's Facility Assessment was updated to include the identified areas as outlined in the statement of deficiencies from the annual survey ending December 20, 2024. 2. Regional Administrator educated NHA & IDT team on importance of maintaining the Facility Assessment accurately to reflect current environment of the facility. 3. Updates to Ridgeview Healthcare and Rehabilitation Center's Facility Assessment will be completed upon changes within the organization or at least annually. 4. Ridgeview Healthcare and Rehabilitation Center's Facility Assessment will be reviewed monthly at the QA Committee meeting for three months and at least annually thereafter.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs, interests, preferences, and functional abilities of its residents, particularly affecting four residents out of a sample of 18. The deficiency was identified through clinical record reviews, resident council meeting minutes, and interviews with residents and staff. The facility's activity program was criticized for lacking variety and engagement, with specific concerns about the use of 'bingo bucks' for prizes, which were often used items. Additionally, the facility did not have a dedicated budget for activities, and the Activity Director, who started in August 2024, confirmed that there were no specific activities for younger residents or those with mental health needs. The report highlighted that the activity preferences for some residents had not been reviewed for over a year, indicating a lack of personalized care planning. The facility's activity calendars for the months leading up to the survey showed a lack of variety and programming for younger residents, despite a significant portion of the resident population being under 60 and having mental health diagnoses. Interviews with residents revealed dissatisfaction with the current activities, describing them as boring and not aligned with their interests or preferences. The facility's failure to develop and implement a comprehensive activity program that addresses the diverse needs of its residents, including those with higher cognitive functioning and younger residents, was a significant factor in the deficiency.
Plan Of Correction
1. R-18, R-16 & R-19 will be interviewed by Activity Director to identify their interest in activity programs and bingo prizes. 2. Activity department will discuss activity planning during resident council meetings to engage feedback from residents on the activities they do or do not like. 3. Activity Director has been reeducated on planning activities to meet the needs, interests, preferences and functional abilities of the current resident population. 4. NHA/designee will meet monthly with residents to ensure their activity preferences are being addressed and planned as able into the activity calendars. A summary of each meeting will be submitted to the QA Committee monthly.
Inadequate Supervision and Environmental Safety in LTC Facility
Penalty
Summary
The facility failed to implement effective interventions and provide adequate supervision to prevent repeated falls for two residents. Resident 52, who has severe cognitive impairment due to Huntington's disease, experienced multiple falls despite being identified as at high risk. The interventions in place, such as using a call light, were not suitable given the resident's cognitive limitations. The facility did not provide sufficient staff supervision or document effective interventions to prevent these falls, as evidenced by multiple incidents where the resident was found on the floor. Resident 49, who has moderate cognitive impairment and is dependent on staff for wheelchair mobility, fell in the dining room when attempting to sit back down in a wheelchair that rolled away. The staff failed to ensure the wheelchair locks were engaged, which directly contributed to the fall. The facility did not provide documented evidence that measures were taken to ensure the locks were engaged prior to the incident, compromising the resident's safety. Additionally, the facility failed to maintain a safe environment in a third-floor shower room, where a resident reported being burned by fluctuating water temperatures. The maintenance director acknowledged an issue with the facility's boiler, and the water temperature was found to be inconsistent. Staff did not check water temperatures before resident showers, and there was no assessment to determine if residents could safely shower independently. This oversight led to a resident experiencing discomfort and potential harm during a shower.
Plan Of Correction
1. R-52, R-49, R-78 & R-48 still reside in the facility. R-41 discharged to another SNF. 2. IDT Team met for R-52 and her individual care plan has been updated for safety interventions. R-49 is able to unlock his breaks independently; Fall(s) attributed to the acute onset and surgical intervention of Acute Appendicitis, Anti-rollback mechanism added to wheelchair. R-78 & R-48 are not independent in the shower room for showers. After residents were assessed by therapy, no resident was deemed to be an independent shower. 3. Fall prevention & safety education provided to staff. Facility will audit the last two weeks of residents falls to ensure appropriate interventions are in place. Outside plumber identified an issue with the main mixing valve on the water heater and replaced. Staff educated on taking water temperatures prior to showering of residents. 4. CNA/Nursing staff will complete purposeful rounding and complete tool five days/week for four weeks, then weekly for two months. Audit of shower temps to be completed three times per week for four weeks and weekly for two months. DON/designee will round three times per week for four weeks with audits submitted to the QA Committee for three months.
Non-compliance with Timely Payment Regulations
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), a facility owner is required to pay bills in a timely manner for services essential to the health and safety of residents. A review of the facility's accounts payable ledger revealed multiple outstanding balances as of December 20, 2024, that were greater than 121 days beyond the terms of payment. These included significant amounts owed to various service providers such as Allstate Pest Management, Concept Medical, and General Healthcare Resources, among others. During an interview, the Nursing Home Administrator confirmed that the facility owners had not provided evidence of payments or payment agreements for the outstanding invoices. Furthermore, the facility administration did not have access to billing or payment records and could not verify whether the listed bills had been paid. This lack of timely payment for essential goods and services demonstrates non-compliance with the regulations, which require facilities to pay bills promptly to prevent jeopardizing the health and safety of residents.
Plan Of Correction
1. January 1, 2025 the company obtained a new accounts payable company. The facility administrator will work with the new company designee to research accuracy of the listed vendors. There are no goods or services that are being withheld from the residents due to the status of the AP liabilities of Ridgeview Healthcare and Rehabilitation Center. 2. The Administrator will receive an AP/Aging report monthly and review the report that bills are paid in a timely manner and continued vital services are rendered for resident care. 3. The Regional Administrator will educate the Administrator on reviewing the monthly vendor AP/Aging report to ensure vital resident services are not interrupted. 4. Administrator/designee will maintain documentation of the monthly review of the AP/Aging reports and implement a monthly accounts payable call to ensure current services for vital goods and vendors are not interrupted and being provided. Results of the monthly accounts payable call will be submitted to the QA Committee for three months for any changes or recommendations.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an alleged misappropriation of resident property involving a resident who was cognitively intact, as indicated by a BIMS score of 15. The resident reported the theft of his cellphone in November to the facility staff, identifying two agency nurse aides as the alleged perpetrators. Despite the resident's prompt notification, the facility did not report the incident to local law enforcement, the State Licensing Agency, or the Local Area Agency on Aging within the required timeframes as outlined in their abuse policy. The facility's investigation lacked documented evidence of timely notifications to the appropriate authorities, and a PB-22 form was not completed within five working days for the alleged perpetrators. The resident independently contacted law enforcement, which initiated a police investigation. The facility's administrator confirmed the failure to adhere to the established reporting procedures, which delayed the investigation and response to the resident's allegation.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. Facility conducted an immediate investigation upon learning about the allegation. Local police were notified, and the facility replaced the alleged stolen phone, which the resident did not accept. Facility subsequently did report this event to the DOH on 12/20/2024. 2. Facility will audit last 30 days of grievances to ensure facility has made appropriate reports of any alleged misappropriation of resident property. 3. IDT team will be educated on reporting requirements of alleged misappropriation of resident property. 4. NHA/Designee will conduct audits of grievances to ensure any allegation of misappropriation of resident property has been timely reported to the DOH. Audits will be conducted three times per week x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. All results will be reported to the QAPI Committee.
Deficiency in Person-Centered Dialysis Care
Penalty
Summary
The facility failed to provide person-centered care for a resident who required hemodialysis, specifically in the management of their arteriovenous (AV) fistula. The resident, who was admitted with end-stage kidney disease and dependent on dialysis, had a right arm AV fistula for dialysis access. Physician orders specified dialysis days and times, as well as instructions for the care of the AV fistula, including checking for bruit and thrill daily and using an emergency kit at the bedside. However, these orders did not detail specific care for the AV fistula. The resident's care plan included general interventions related to dialysis access but lacked individualized interventions for the monitoring, care, maintenance, or emergency management of the AV fistula site. During an interview, the Director of Nursing confirmed the absence of a care plan that included emergency measures or planned care specific to the AV fistula for this resident. This oversight was identified as a deficiency in providing appropriate dialysis care and services.
Plan Of Correction
1. R-60's Dialysis care plan was updated. 2. Care plans for other residents with Dialysis have been reviewed and addressed accordingly. 3. Quarterly review of care plans for Dialysis residents will occur to ensure individualized care plans. 4. Monthly audit of Dialysis resident's care plans to ensure accuracy for three months. Audits will be submitted to the QA Committee for three months.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. On December 19, 2024, at 9 A.M., an LPN administered over-the-counter medications to a resident by pouring pills into her ungloved hand, transferring them into a plastic medication cup, and handing the cup to the resident. The medications included Vitamin B1, Vitamin B12, and a multi-vitamin. At 9:05 A.M., the same LPN repeated this practice with another resident, administering a multi-vitamin and Vitamin B1. Additionally, the LPN dropped a capsule on the top of the medication cart, picked it up with her ungloved hand, placed it into a plastic medication cup, and provided it to the resident. During an interview on December 20, 2024, the Director of Nursing confirmed that these practices constituted a breach of infection control standards during medication administration. The facility's failure to follow proper infection control practices placed residents at increased risk of infection and compromised their safety.
Plan Of Correction
1. R-57 & R-34 had no ill effects from incorrect handling of the OTC/vitamins during the medication pass on December 19, 2024. 2. Employee 1 received 1:1 education on proper medication handling and administration of any OTC/vitamin. Education to remaining LPN/RN's on proper medication handling and administration of any OTC/vitamin. 3. Audit(s) will be conducted on correct medication administration of OTC/vitamins three times per week for 4 weeks; weekly times 4 weeks and randomly for 4 weeks. 4. Results of the medication audits will be submitted to the QA Committee for three months.
Non-compliance with Act 52 Infection Control Requirements
Penalty
Summary
The facility failed to comply with the requirements of Act 52 regarding its infection control plan. The deficiency was identified through a review of the facility's infection prevention and control policy, which was last reviewed in October 2024. The policy was intended to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infections. However, it was found that the facility's infection control policy and procedures did not include all the necessary requirements mandated by Act 52. Specifically, the facility did not establish a multidisciplinary committee with representatives from various groups, as required by the Act, to oversee the infection control plan. During an interview, the Infection Preventionist confirmed that the facility's infection control policy did not meet the requirements of Act 52. It was revealed that infections were reported to the state agency at the end of each month, rather than within the required 24-hour timeframe. This reporting method was based on the Infection Preventionist's previous practice at another facility, which did not align with the current regulatory requirements. No evidence was provided during the survey to confirm the facility's compliance with Act 52, leading to the identification of this deficiency.
Plan Of Correction
1. The Infection Preventionist is now reporting any HAI (Healthcare Associated Infections) to the PA-PSRS system within 24 hours of confirmation. 2. Education provided to the Infection Preventionist on reporting requirements on HAI's to the PA-PSRS system. 3. The DON/designee will audit the HAI's submission timeframe weekly for four weeks and monthly for two months. 4. Results of the audits will be submitted to the QA Committee for three months.
Failure to Ensure Timely Payment for Essential Services
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. A review of the facility's accounts payable ledger revealed numerous outstanding balances as of December 20, 2024, with amounts overdue by more than 121 days. These unpaid bills included essential services and supplies from various vendors such as Allstate Pest Management, Geisinger Medical Center, and Nutro Co, among others. The total outstanding amount was substantial, with significant debts owed to entities like Total Plan Concepts and the West Mahanoy Township Tax Collector. During an interview, the Nursing Home Administrator confirmed that the facility owners had not provided evidence of payments or payment agreements for the outstanding invoices. Furthermore, the facility administration did not have access to billing or payment records, preventing them from verifying whether the listed bills had been paid. This lack of payment for essential goods and services demonstrates non-compliance with regulations requiring facilities to pay bills in a timely manner to prevent jeopardizing the health and safety of residents.
Plan Of Correction
1. January 1, 2025 the company obtained a new accounts payable company. The facility administrator will work with the new company designee to research accuracy of the listed vendors. There are no goods or services that are being withheld from the residents due to the status of the AP liabilities of Ridgeview Healthcare and Rehabilitation Center. 2. The Administrator will receive an AP/Aging report monthly and review the report that bills are paid in a timely manner and continued vital services are rendered for resident care. 3. The Regional Administrator will educate the Administrator on reviewing the monthly vendor AP/Aging report to ensure vital resident services are not interrupted. 4. Administrator/designee will maintain documentation of the monthly review of the AP/Aging reports and implement a monthly accounts payable call to ensure current services for vital goods and vendors are not interrupted and being provided. Results of the monthly accounts payable call will be submitted to the QA Committee for three months for any changes or recommendations.
Failure to Maintain Emergency Lighting
Penalty
Summary
The facility failed to maintain battery-powered emergency lighting in two locations, affecting two of four floors. During an observation on December 11, 2024, between 10:28 a.m. and 10:43 a.m., it was noted that the battery back-up emergency lights did not illuminate when tested. Specifically, at 10:28 a.m., Emergency Light #10 on the 3rd floor near Resident room 308 failed to function. Similarly, at 10:43 a.m., Emergency Light #21 at the Nurse's station on the 2nd floor also did not illuminate. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:15 a.m.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. Batteries in Emergency Lights #10 & #21 were replaced. 2. Whole house test of Emergency Lights completed and addressed accordingly. 3. Education to the Maintenance Director and Maintenance staff on ensuring testing and maintenance of the Emergency Lights in the facility. 4. Weekly testing of Emergency Lights for 4 weeks; monthly testing of Emergency Lights for 2 months. Results of audit(s) to be submitted to the QA Committee Meeting monthly.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the sprinkler system, which provides fire protection, in two instances affecting two of four floors. On December 11, 2024, at 10:19 a.m., an observation on the 1st floor in the Therapy Room revealed a missing ceiling tile near the windows. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager. Additionally, between 10:27 a.m. and 10:32 a.m., observations on the 3rd floor identified two issues: a sprinkler head in the Shower Room was not sealed into the escutcheon, creating a gap, and a gap was also found around the sprinkler escutcheon in the ceiling near the Bathing Room corridor. These sprinkler deficiencies were also confirmed during the exit interview.
Plan Of Correction
1. The missing ceiling tile in the therapy gym was replaced. The ceiling tiles around the escutcheon(s) located in the 3rd floor shower room and 3rd floor corridor outside the bathing room were corrected to eliminate the gap identified. 2. A one-time facility audit conducted to ensure no gaps were identified around other escutcheons in the facility. 3. Education to the Maintenance Director and Maintenance staff to ensure no gaps are present around any escutcheons in the facility. 4. A monthly audit will be completed for three months to ensure no gaps are present around the escutcheons in the facility. Results of audit(s) to be submitted to the QA Committee Meeting monthly.
Unlocked Electrical Panel on First Floor
Penalty
Summary
The facility failed to maintain the security of electrical panels on the first floor, as observed on December 11, 2024. During the inspection, it was noted that a corridor wall-mounted recessed electrical panel near the Game Room was left unlocked, making it accessible to unauthorized persons. This observation was confirmed during an exit interview with the Facilities Manager and the Facility Administrator.
Plan Of Correction
1. The electric panel on the 1st floor, outside the movie room, was locked. 2. A one-time audit performed to ensure that the electric panels are appropriately locked. 3. Education to the Maintenance Director and Maintenance staff to ensure that the electrical panels are appropriately locked unless the panel is being accessed by appropriate personnel. 4. Audits will be completed monthly for three months to ensure that electrical panels are locked when not being accessed. Results of the audit(s) will be submitted to the QA Committee Meeting monthly.
Absence of Designated Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with regulatory requirements for infection prevention and control due to the absence of a designated Infection Preventionist (IP). The facility's Infection Control Policy, last reviewed on June 3, 2024, did not mention the need or role of an IP. During a survey conducted on September 10, 2024, it was revealed that the facility did not employ an IP, as confirmed by the Director of Nursing. The previous IP had left the facility on August 7, 2024, and since then, no individual had been appointed to fulfill the role. The Nursing Home Administrator confirmed that the facility's infection prevention and control program was not being completed as required by regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 249 citations issued within 25 miles in the last 12 months — including the 4 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shenandoah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shenandoah Senior Living Community | 0.4 mi | ★★★★★ | 15 | 1 |
| Broad Mountain Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 16 | 1 |
| Schuylkill Center | 9.1 mi | ★★★★★ | 16 | 0 |
| Edenbrook Of Greenwood Hill | 9.8 mi | ★★★★★ | 4 | 0 |
| Green Valley Skilled Nursing And Rehabilitation Ce | 10.5 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.