Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Rochester Residence And Care Center during CMS and state inspections, most recent first.
The facility failed to comply with disclosure of ownership and administrative change requirements by not notifying the State Agency when its NHA left and by not ensuring a qualified NHA was assigned for a two-day period. Written communications showed that the outgoing NHA informed the State Agency of his last day after the fact, and the State Agency then sought clarification from the facility’s VPO about who was acting as NHA. The VPO indicated he was acting as NHA but had been out ill, and review of the timeline confirmed there was no assigned NHA for two days. The DON later confirmed that the facility did not notify the State Agency at the time of the NHA change and did not have an NHA assigned during that period, constituting noncompliance with state requirements for licensee responsibility.
The facility failed to maintain a safe and functional environment by not ensuring that the employee entrance door remained properly secured. Policy required a preventative maintenance program to keep the environment safe and functional, and a resident representative had reported that the employee entrance, which was supposed to be locked and require a code, did not safely close or lock and was accessible to the public. During surveyor observation with the Maintenance Director, the door could be opened from outside without entering a code because it did not fully close and latch, and staff confirmed the door was not latching properly and had previously been broken. The DON acknowledged that the facility failed to ensure a safe, functional environment for this entry door.
The facility failed to maintain an effective pest control program on the third floor, where multiple resident representatives, staff, and family members reported rats running through the building and rat traps placed in patient rooms. The DON and Administrator were reported as denying rodent presence despite evidence of dead rodents, droppings, and traps, while the Maintenance Director acknowledged staff reports of rats, especially at night, and confirmed traps had been placed in some resident rooms. An RN reported seeing rats during the day, hearing them in the ceiling, and observing rat feces in a bathroom. Review of pest control records showed only standard, fly light, and bed bug services with no rodent-specific services. A pest control vendor called to the facility found poorly maintained outdoor bait stations being used as shelter by live rats and rat fecal evidence on the third floor, and noted that an existing trap there was too small for a rat.
Inadequate supervision led to a wandering resident leaving the unit and ending up in another area of the facility after exit-seeking behavior was noted. The resident had a wander guard order, severe cognitive impairment, and a care plan that identified elopement risk but did not list triggers for exit seeking. Staff statements described alarms sounding, the resident being found downstairs by PCU staff, and conflicting documentation about whether the event was a wandering incident or an elopement.
Food storage and sanitation failures were observed in the Main Kitchen and a third-floor kitchenette. In the Main Kitchen, several dry goods were not labeled or dated, an opened mix lacked an open date, and a scoop was stored inside a flour bin. In the kitchenette, the ice machine was covered with a sheet, temp logs were incomplete, and multiple refrigerated items were unlabeled, undated, or expired, including milk, bread, a bagel, and bowls of cereal.
QAPI Committee Failed to Correct Repeat Deficiencies: The facility QAPI committee failed to correct quality deficiencies or ensure that plans to improve care and services effectively addressed cited issues. Review of facility records and the current survey showed multiple repeat deficiencies from the prior survey, and the President of Operations confirmed that the facility had not corrected them.
Crash carts were not kept in safe operating condition for two crash carts. The Fourth Floor crash cart checklist had missing signatures and a missing monthly signature page, and an RN confirmed it should be checked nightly. The Third Floor crash cart contained expired suction tubing and a Yankauer, plus an open bottle of sterile water with contents missing and a brown substance floating in it; an LPN stated she had never seen a check log for that cart.
Resident Call Bell System Not Reliably Functioning on Third and Fourth Floors: Surveyors observed multiple kiosks on the Third and Fourth Floor units that displayed activated call bells but did not chime, were black or unplugged, or showed error messages. Staff reported relying on visual checks, said pagers were not being used, and acknowledged that the call bell system was not consistently functioning. The VPO confirmed the facility failed to maintain a fully functioning resident call bell system for resident access to staff assistance.
Unsafe and poorly maintained resident areas were observed on the Third and Fourth Floors. A resident room bathroom sink was repeatedly not draining and was dripping, and a nurse aide said the problem recurred in many rooms and made it difficult to get hot water for baths. Surveyors also found missing and stained ceiling tiles, broken and unpainted plaster, peeling paint, chipped walls, and dark brown areas in shower rooms and bathrooms; a maintenance employee and the President of Operations confirmed the findings.
Failure to Communicate Transfer Info and Bed-Hold Notice The DON confirmed that the facility did not communicate required transfer information to the receiving provider for five residents who were sent to the hospital, including care plan goals, advance directives, ongoing care instructions, and resident representative info. The records also lacked evidence that the resident or RP received written notice of the bed-hold policy for these hospital transfers. The affected residents had diagnoses including HF, DM, dementia, malnutrition, Down Syndrome, HTN, and hemiplegia.
Failure to Notify Physician of Elevated BG and Follow Weight Orders: Three residents with DM had repeated high CBG readings, but the records did not document physician notification, and the orders lacked parameters for when to call the MD. An RN confirmed the missing documentation and stated the physician should be notified for readings over 400. In addition, a resident with lymphedema did not have weights obtained consistently as ordered twice weekly.
Failure to assess and document pressure ulcer care for multiple residents. Two residents with PU/PI diagnoses had wounds documented without measurements at admission, and a third resident with a Stage 3 pressure injury had multiple missed TAR sign-offs for ordered treatment plus missing weekly skin assessment documentation. Facility staff confirmed the lack of assessment, monitoring, and treatment consistent with professional standards of practice.
Failure to Provide Appropriate Respiratory Care Five residents with orders for O2 and/or nebulizer tx had respiratory equipment that was not maintained per policy. Findings included tubing that was dated outside the expected schedule or not labeled, and nebulizer equipment left out on a bedside table or not stored in a plastic bag when not in use. An RN and the President of Operations confirmed the deficient respiratory care.
Unsecured treatment cart, lab supplies, and unlabeled medications: The 4th Floor treatment cart was observed unlocked and unattended, and a portable caddy with blood collection needles and tubing was also left unsecured at the nurses station. In addition, two Lantus insulin pens on the Grandview med cart had no resident name or open/expiration date, and three cups of unmarked, unlabeled pills were found unsecured in the Riverview med cart drawer; an RN and LPN confirmed the findings.
The former NHA and DON did not effectively manage the facility to ensure proper supervision for residents at high risk for elopement, and a resident elopement occurred, creating an immediate jeopardy situation. The report states the NHA was responsible for overseeing operations and resident incidents, while the DON was responsible for directing nursing services, monitoring incidents, and reporting unusual occurrences, but the facility failed to ensure residents received care in accordance with professional standards and facility policies.
Missing Current Hospice Documentation: The facility failed to maintain current hospice records for three residents receiving hospice services. One resident with DM, HTN, and anxiety had a hospice order but no hospice communication or binder with a current plan of care. Another resident with high BP, hyperlipidemia, depression, and end stage cardiac disease had only an outdated hospice plan of care in the chart. A third resident with DM, dementia, and respiratory failure had a hospice binder with an old plan of care and no current hospice documentation.
Hand hygiene supplies were unavailable across multiple nursing units, with empty sanitizer dispensers and missing hand soap in many resident rooms and storage areas. During a wound dressing change, an RN did not perform hand hygiene before gloving, after cleansing the wound, or before applying the new dressing. The facility also failed to monitor a resident-owned refrigerator temperature and did not obtain or document final blood culture results for another resident after hospital discharge.
Failure to timely offer and document COVID-19 vaccination: The facility did not timely offer or provide the COVID-19 vaccine for three residents. Records showed two residents were not up to date on COVID-19 vaccination, and one resident/family was educated about vaccines but the chart did not show the COVID-19 vaccine was administered, declined, or otherwise documented. An IP stated COVID vaccines had been offered, but the facility was waiting to do a large administration after switching pharmacies.
Call bells were not kept within reach for two residents while they were lying in bed. One resident had HTN, HLD, and depression, and the other had HTN, HLD, and dementia. Both call lights were wrapped around the headboard and out of reach, and a nurse aide confirmed they were not accessible or available for use.
Unnecessary Psychotropic Medication Use: A resident received risperidone for agitation and later for dementia with behavioral symptoms and psychotic features, while the care plan identified psychotropic medication use and related diagnoses. An RN confirmed the resident did not have a diagnosis for the use of risperidone and that the facility failed to ensure the drug regimen was free from unnecessary medication used without adequate indications.
Failure to Verify Credentials Before Hire: The facility failed to complete required pre-employment screening for two newly hired staff members before hire. A NA and an LPN were hired without a completed certification/license check in their personnel records, despite facility policies requiring screening for abuse, neglect, exploitation, misappropriation of resident property, and verification of credentials through the appropriate issuing agency.
A resident’s MDS was coded inaccurately and did not reflect diuretic use or hospice care. The record showed the resident was ordered Lasix for CHF and received it as ordered, and hospice services had also been ordered for the resident. The RNAC confirmed the MDS should have included both the diuretic therapy and hospice care.
Improper Indwelling Catheter Care and Incomplete Orders: Two residents with indwelling urinary catheters were observed with drainage bags that were not covered as required. One resident had a Foley catheter ordered for urinary retention, and staff confirmed the bag was uncovered. For the other resident, staff also confirmed the uncovered bag, and the catheter care order lacked key details such as catheter type, size, diagnosis, and balloon inflation amount.
Failure to provide adequate care for a resident's midline catheter. The resident had orders for IV NS and a one-time midline placement for IV fluids, and progress notes later documented the line as patent and without signs of infiltration or infection. However, an observation showed the midline still in place with a dressing dated from the original placement, and an RN confirmed there were no orders for flushes or dressing changes.
The facility failed to complete an annual performance evaluation for a nurse aide within the required 12-month timeframe. Personnel record review showed the aide was hired in 10/23 and the most recent evaluation was completed in 1/24, and HR confirmed no evaluation had been done in 2025.
A resident with dementia and a BIMS score indicating moderate cognitive impairment did not have an individualized person-centered care plan addressing dementia and cognitive loss. The resident’s care plan did not reflect the resident’s symptomology or cognitive needs, and the RNAC confirmed the facility failed to develop and implement the required dementia-focused care plan.
The facility failed to provide required Effective Communication training for two RNs. Review of personnel files showed both staff members lacked annual training in this topic, and HR confirmed the deficiency during interview. The facility policy required this training for all staff as part of its training program.
Failure to provide required Resident Rights training for two RNs. Facility policy required all staff to receive training on Resident Rights before independently providing services and on an annual basis. Review of personnel files showed two RNs did not have the required training during the applicable annual periods, and HR confirmed the lapse.
Missing Required Abuse, Neglect, and Exploitation Training The facility failed to provide required Abuse, Neglect, and Exploitation training for two of five staff members, including two RNs. Facility policy required all staff to receive this training as part of the annual training program, but personnel file review showed the two RNs did not have the required training within the applicable annual periods. HR confirmed the training was not provided as required.
The facility failed to provide required QAPI training for two RNs. The facility policy required all staff to receive training, including QAPI, before independently providing services and on an ongoing basis. Personnel file review showed no documented QAPI training for the two RNs during the required annual periods, and HR confirmed the lapse.
The facility failed to provide required Infection Control training for two RNs. The facility policy required staff training on the Infection Prevention and Control Program before independent service and annually, but two RN personnel files showed no annual Infection Control training during the required periods. HR confirmed the missing training during interview.
Failure to provide required Compliance and Ethics training was identified for two RNs. Facility policy required annual training for all staff, but personnel records showed no documented training for either RN during the required review periods. HR confirmed the missing training during interview.
Behavioral Health training was not provided for two RN staff members as required by facility policy and the facility assessment. Personnel records showed both RNs lacked the required annual training during the applicable review periods, and HR confirmed the deficiency.
Surveyors found that the facility did not maintain room temperatures within the policy range of 71–81°F and did not monitor residents for hypothermia when the heating system was not fully functional. The NHA knew the heat was not working properly, but only limited room audits were done and staff did not systematically assess or interview all residents about cold-related needs. Temperature checks showed many rooms on upper floors below 71°F, with some as low as the upper 50s, and several residents reported feeling cold and were observed bundled in multiple blankets, coats, or caps. Staff acknowledged that residents complained of being cold and that extra blankets were brought in, yet residents reported that staff had not proactively offered extra blankets or warm fluids. Record reviews for several residents showed no physician orders for hypothermia monitoring and no recent temperature documentation despite the environmental issue, and the NHA confirmed the failure to maintain required temperatures and to monitor all residents for hypothermia, which was cited at the Immediate Jeopardy level.
Surveyors found that the facility did not follow its own garbage and refuse disposal policy, which requires adequate receptacles and a clean surrounding area to minimize debris and pest attractions. During observation, the outdoor trash compactor area contained shopping carts, an oversized chair, numerous empty cardboard boxes, and many filled garbage bags left outside the dumpster rather than properly contained. In an interview, the Nursing Home Administrator confirmed that trash and debris were accumulating in the disposal area and that the facility failed to properly contain and dispose of garbage in the outside dumpster area.
A resident with dementia, anemia, and HTN, and a BIMS score indicating moderate cognitive impairment, was found in bed with a cup containing four pills left on the bedside table and no nurse present. Facility policy required an IDT assessment, physician order, and care plan before allowing self-administration of medications, but the resident’s record lacked a self-administration assessment, an order for self-administration, and any care plan addressing it. An RN acknowledged leaving the medications at the bedside as an oversight, and the DON confirmed the facility had not determined whether it was safe for the resident to self-administer medications.
Surveyors found that three medication carts (Vineyard, Rosewood, and Rosewood 2) were left unattended in hallways with computer screens open, displaying identifiable resident medical information visible to anyone passing by. An LPN and two RNs acknowledged that the carts had been left with confidential information on the screens while they were away from the carts, including when one RN was in a resident room. The administrator confirmed that this practice failed to maintain the confidentiality of residents' medical records as required by facility policy and state regulations.
Surveyors found that, several days after a snowstorm, the facility had not adequately cleared snow from two parking lots, sidewalks, and multiple exits. The main parking lot used for visitors, transport, and ambulances had only one plowed entrance, with the exit blocked by snow, and sidewalks to the building were not shoveled. A second parking area remained unplowed with vehicles stuck. A family member reported that the area was a disaster and that you could not get in or out. The NHA stated the contracted snow removal company never arrived and acknowledged that the facility failed to evaluate the snow hazard and implement an effective snow removal plan, leaving two of three exits with uncleared walkways.
Surveyors found that three of four medication carts (Vineyard, Rosewood, and Rosewood 2) were left unlocked and unattended in hallways, contrary to the facility’s Medication Storage policy requiring all drugs and biologicals to be kept in locked compartments or under direct observation during medication passes. An LPN and two RNs each confirmed that their respective carts were unsecured while they were not present at the carts, and the Nursing Home Administrator acknowledged that the carts were not properly secured as required by policy and state regulations.
Surveyors found that the NHA and DON did not ensure that indoor air temperatures were kept within the required 71–81°F range and did not monitor or assess any residents for hypothermia, despite job descriptions requiring them to oversee operations, perform rounds, and ensure resident needs were met. Review of job descriptions, clinical records, observations, and staff interviews showed that these omissions affected all residents and resulted in an Immediate Jeopardy situation due to noncompliance with federal and state regulations.
Kitchen equipment was not maintained in a sanitary condition, creating the potential for cross contamination in the main kitchen. During an observation with the CDM, the walk-in cooler’s cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and ceiling area in front of the fans, and the CDM confirmed the finding.
Improper Garbage Disposal and Dumpster Area Housekeeping: The facility failed to properly contain and dispose of garbage in the outside dumpster area. Facility policy required dumpsters to be kept covered when not in use and the surrounding area kept clean, but during observation an CDM confirmed trash and debris were collecting in the disposal area.
Failure to maintain resident dignity during catheter care and meals: two residents with Foley catheters were observed with drainage bags hanging uncovered without privacy bags, despite orders to keep them covered. A dependent resident ordered to be assisted with dining was left with lunch sitting at the nurse's station until an RN fed him later, and the meal was cold. Residents also reported meals were routinely served on foam plates with plastic silverware, and the DON confirmed the facility had been serving disposable dinnerware for several months.
Inadequate Linens and Unclean Shower Areas: Surveyors found severe linen shortages on the 3rd and 4th floors, with ripped towels and bath blankets being used in place of washcloths, no towels or pillowcases on one rack, and staff reporting they could not complete morning care or baths/showers because supplies were lacking. On the 3rd floor, a resident's privacy curtain was soiled, a room left ready for admission still had a dirty urinal, and the shower room had debris, discoloration, rust, peeling ceiling material, a hole in the ceiling, and an open bottle of vinegar left on the floor; the NHA confirmed the environment was not clean, safe, or homelike.
Failure to ensure hand hygiene, prevent cross contamination during a dressing change, and maintain an effective infection prevention and control program was identified. Empty sanitizer dispensers were observed throughout the unit, an LPN performed a wound dressing change without handwashing between glove changes and used unclean scissors, and the facility lacked required surveillance floor mapping for multiple months. The DON also confirmed delayed COVID outbreak response after an RN tested positive, with delayed resident testing, no contact tracing, and inadequate precautions observed around a resident with COVID.
Failure to Verify Safe Self-Administration of Medications: The facility allowed medications to be kept at the bedside for three residents without documented provider orders or care plan support for self-administration. Observations found topical meds and a pill at the bedside, and an RN confirmed the meds were present without the required authorization; one resident with dementia also stated they did not want to take the pill.
Unnecessary Psychotropic Medications Not Properly Reviewed: The facility failed to ensure psychotropic regimens were properly reviewed for four residents. Records showed missing physician responses to MRRs, no documented GDR for an antidepressant in one resident, PRN Xanax ordered without a 14-day stop date or documented rationale in another resident, and no documented nonpharmacological interventions before PRN use. The DON confirmed the medication regimens were not free from unnecessary psychotropic medications.
Failure to Obtain Ordered Weights for Residents With Weight Loss: The facility failed to obtain ordered weekly weights for four residents with significant medical issues, including ESRD, dementia, Down Syndrome, and documented weight loss. Records showed missed weights despite physician orders for weekly monitoring, and the RD confirmed the missing weights for multiple residents.
Failure to provide proper nebulizer care for three residents. Residents with COPD, ESRD, aphasia, hemiplegia, MS, and respiratory failure had ordered nebulizer treatments, but observations found nebulizer machines, masks, and mouthpieces left out on bedside surfaces instead of stored in bags, and tubing was not dated or was dated beyond the required interval. An LPN and RN confirmed the improper storage and dating.
Incomplete dialysis communication and missing care plan. The facility failed to maintain complete dialysis communication with the dialysis center for three residents receiving HD. One resident had ESRD, aphasia, and hemiplegia; another had metabolic encephalopathy, anemia, and HF; and a third had ESRD, HTN, DM, and an external hemodialysis catheter. Records showed missing or incomplete dialysis communication forms, and the DON confirmed one resident’s care plan did not include dialysis or the catheter.
Failure to Timely Report NHA Change and Maintain Assigned Administrator
Penalty
Summary
The facility failed to notify the State Agency (SA) of a change in the Nursing Home Administrator (NHA) at the time of the change and failed to ensure that a qualified NHA was assigned to the facility for two days. Written communication dated 3/29/26 showed that NHA Employee E3 informed the SA that his last day as NHA at the facility was 3/27/26. A subsequent written communication dated 3/30/26 from the SA to the facility’s President of Operations (VPO) Employee E4 requested clarification regarding who was acting as NHA, as the SA had been made aware of Employee E3’s departure. VPO Employee E4 responded that he was acting as NHA “for now” and noted he had been out with an illness and would provide the requested information as soon as possible. Review of this information revealed that no NHA was assigned to the facility from 3/28/26 through 3/29/26. In an interview on 4/1/26 at 9:00 a.m., the Director of Nursing confirmed that the facility did not notify the SA of the NHA change at the time it occurred and did not have an NHA assigned during that two-day period, in violation of PA Code 201.14(a) regarding responsibility of the licensee. No residents or specific clinical conditions were mentioned in the report, and the deficiency pertains solely to administrative oversight and regulatory noncompliance related to NHA assignment and notification requirements.
Failure to Maintain Secure and Functional Employee Entrance Door
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, functional, and secure environment at one of two entry doors, specifically the employee entrance. The facility’s preventative maintenance policy, last reviewed on 12/11/25, required a program to ensure a safe, functional, sanitary environment for residents, staff, and the public. A resident representative concern dated 2/27/26 reported that the employee entrance, which was supposed to remain locked and require a code for entry at all times, did not safely close or lock and was accessible to anyone from the public. During a surveyor observation with the Maintenance Director, the employee entrance was described as having a motion sensor for exit and a keypad requiring a code for entry. However, when the surveyor went outside and tested the employee entrance, the door could be opened without entering a code because it did not fully close and latch properly. The Maintenance Director and a maintenance employee confirmed during the observation that the door was not latching properly. The Maintenance Director stated that the door had been broken a couple of weeks earlier and had been fixed, but they were not aware it had become broken again. Later the same day, the Maintenance Director confirmed the door remained broken and that the lock was broken and required a vendor to replace it. The DON confirmed that the facility failed to ensure a safe and functional environment for the employee entrance door.
Failure to Maintain Effective Pest Control on Third Floor Unit
Penalty
Summary
The facility failed to maintain an effective pest control program on one of two nursing units, specifically the third floor, despite multiple reports and evidence of rodent activity. The written Pest Control Program dated 12/11/25 required eradication and containment of common household pests, including mice and rats. A resident representative concern documented that rodents were running around the building, rat traps were placed in patient rooms, and over a dozen rodents had been seen. Another resident representative concern stated that the DON and Administrator denied the presence of rodents despite proof of dead rodents, droppings, and rat traps in patient rooms, and reported that rats were seen by patients, staff, and family members. Staff interviews confirmed rodent sightings, with the DON acknowledging that rodents had been seen in the building and that there were reports of rats, particularly on the third floor. The Maintenance Director reported receiving staff reports of rats seen at night on the third floor and acknowledged that traps had been placed in some resident rooms, some initially within residents’ reach before he moved them. Review of pest control vendor documentation showed only standard monthly, fly light, and bed bug services in the relevant period, with no listed rodent services. An RN reported seeing rats during the day, hearing them in the ceiling, observing what appeared to be a pregnant rat over several weeks, and photographing a pile of rat feces in a bathroom corner, which housekeeping was called to clean; the RN stated no exterminators had been seen and rats were still present. A second pest control vendor, called on the day of the survey, reported finding several outdoor bait traps by the dumpster that were not maintained and were being used as shelter by live rats, and found rat fecal evidence on the third floor, noting that an existing trap there was too small for a rat. The DON ultimately confirmed that the facility failed to maintain an effective pest control program for one of two nursing units.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as being at high risk for wandering, resulting in an elopement event. The resident had a physician order for a wander guard for safety related to elopement and exit seeking, and the clinical record included an elopement evaluation showing a score of 25, indicating elopement risk. The resident’s care plan identified him as at risk for elopement, but it did not identify any triggers that might cause exit-seeking behavior. The resident’s MDS documented hypertension, depression, hyperlipidemia, and severe cognitive impairment on the Brief Interview for Mental Status. During the incident, staff statements described the resident as exit seeking and being redirected earlier in the shift near the medication cart. One LPN stated the resident came to the cart while narcotics were being counted and was redirected, and that there were a couple of instances during the shift when he was exit seeking. Another staff member stated she heard a back door alarm, found a man in the back hall, offered him tea, and later brought him back upstairs, but could not confirm whether he came through the stairwell. Another LPN stated she responded to alarms at the back of the hall and stairwell, then learned from staff on another floor that the resident was downstairs and went to retrieve him. The resident was described as pleasantly confused and not injured. Documentation in the record was inconsistent about the event. A nursing progress note described increased exit-seeking behavior and ineffective redirection, while later documentation stated the episode was clarified as a wandering incident and that the resident never eloped from the facility. Staff interviews indicated disagreement about whether an alarm was heard and whether the resident had left the unit or facility. One nurse stated she would 100 percent consider it an elopement and said there was no staff member with the resident when he was found downstairs. The resident was observed later with a wander guard and one-on-one supervision, and staff stated he had gone out the back stairway down two flights of stairs into the personal care facility.
Food Storage and Sanitation Failures in Kitchen Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the Main Kitchen by not properly labeling and dating food products and by storing a serving scoop inside a food container. During an observation in the dry storage area, a bag of croutons, a bag of muffin mix, and a bag of gingerbread mix were found without a receive date label, and a bag of cream soup base mix was opened without a date showing when it was opened. In the cook's area, a large bin of flour had the scoop stored inside the bin. An employee confirmed that the facility failed to properly label and date food products and properly store a serving scoop in the Main Kitchen. The facility also failed to maintain sanitary conditions in the third-floor kitchenette. The ice machine was covered with a sheet instead of a lid, temperature log sheets for January and February 2026 were incomplete, and several items in the refrigerator were not labeled or dated, including blue cheese dressing, Sara Lee bread, a bagel, and bowls of Fruit Loops. The refrigerator also contained multiple expired milk items. A registered nurse confirmed that the facility failed to maintain sanitary conditions, creating the potential for cross contamination in the kitchenette.
QAPI Committee Failed to Correct Repeat Deficiencies
Penalty
Summary
The facility QAPI committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed cited deficiencies. Review of facility documentation, the prior State Survey and Certification survey ending September 19, 2025, and the current survey ending February 13, 2026, showed that the facility had developed plans of correction with quality assurance systems intended to maintain compliance, but the current survey identified multiple repeat deficiencies from the prior survey, including F558, F605, F628, F689, F695, F761, F880, F941, F942, F943, F944, F945, F946, F949, PA1470, PA1550, PA1560, PA1570, and PA1580. During an interview, the President of Operations confirmed that the facility had multiple repeat deficiencies from the previous survey and had failed to correct quality deficiencies and ensure that plans to improve the delivery of care services effectively addressed those deficiencies.
Crash carts were not maintained in safe operating condition
Penalty
Summary
The facility failed to keep crash cart equipment in safe operating condition for two of two crash carts, the Third Floor Crash Cart and the Fourth Floor Crash Cart. Review of the facility’s Emergency Crash Cart policy showed the crash cart is to be checked every 24 hours and after every use, with missing or expired items replaced when applicable. During observation of the Fourth Floor Crash Cart, the crash cart checklist and signature log did not have signatures for several dates, and one monthly signature page was missing. During interview, an RN stated the crash cart should be checked every night and signed for, and confirmed the facility failed to make certain the Fourth Floor Crash Cart was in safe operating condition. Observation of the Third Floor Crash Cart revealed one nonconductive suction tubing set expired, one Yankauer expired, and one 100 milliliter bottle of sterile water that was open, had half of its contents missing, and contained a large brown circular substance floating in the water. At the time of the observation, the State Agency could not locate documentation showing the Third Floor Crash Cart was checked every 24 hours. During interview, an LPN stated she had never seen a check log for this crash cart before and confirmed the facility failed to make certain the Third Floor Crash Cart was in safe operating condition.
Resident Call Bell System Not Reliably Functioning on Third and Fourth Floors
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system that would allow residents to call for staff assistance through a communication system on the Third and Fourth Floor nursing units. Review of the facility policy indicated that call bells were to directly relay to a staff member or centralized location to ensure an appropriate response, and staff were to be educated on proper use of the system and resident access to call bells. During multiple observations, surveyors found that several kiosks at nurses stations and in hallways displayed activated call bells but did not sound a chime, while some kiosks were black, unplugged, or showing an error message. On the Fourth Floor, the kiosk at the nurses station visually displayed a room number when a call bell was activated, but no sound was heard. In other areas, including Hilltop, Riverview, Lilac Lane, Rosewood, Grandview, and Vineyard hallways, the kiosks were inconsistently functioning, with some not chiming, some requiring refreshes to produce sound, and one showing an automatic repair error. The Third Floor nurses station kiosk was observed black and not appearing to be turned on. Staff interviews confirmed the system was not reliably functioning and that staff were relying on visual checks of the kiosks rather than an audible alert. Several staff stated they had not used pagers, had not seen pagers in over a year, or believed the call bells might not be working. The Vice President of Operations acknowledged that the facility failed to maintain a fully functioning resident call bell system on the Third and Fourth Floors and stated that the volume on kiosks had been turned down or disabled because staff believed the chime was loud.
Unsafe and Poorly Maintained Resident Areas on Third and Fourth Floors
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the Third and Fourth Floors. During observations, a sink in the bathroom of a resident room was full of water, did not appear to be draining, and the faucet was dripping. A nurse aide confirmed the sink was not draining and stated maintenance had repeatedly snaked the drain, but the problem returned after a few days. The nurse aide also stated this happened in many resident rooms and made it very difficult to get hot water for baths because the sink would begin to overflow before the water became warm enough. On the Third Floor, surveyors observed two missing ceiling tiles above the television area in a resident room, ceiling tiles with brown and dark spots, broken plaster on the ceiling in Shower Room Stall One, unpainted plaster around the lights, and brown spotted areas with peeling paint in Shower Room Stall Two and above the sink. On the Fourth Floor, surveyors observed plaster peeling and chipping below sinks and around the wall by the floor in two resident bathrooms, paint missing on the wall by the elevator doors, dark brown areas around the edges of both shower stalls, and chipped paint throughout one shower stall. A maintenance employee confirmed the Third Floor findings and the Fourth Floor findings, and the President of Operations confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for the Third and Fourth Floors.
Failure to Communicate Transfer Information and Bed-Hold Policy
Penalty
Summary
The facility failed to make certain that necessary resident information was communicated to the receiving health care provider for five of five residents who were transferred to the hospital and expected to return. The missing information included the resident's care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information necessary to meet the resident's specific needs at the receiving facility. The deficiency was identified through review of the facility's transfer and discharge policy, clinical records, and staff interview. Resident R2 was admitted with diagnoses including heart failure, diabetes, and dementia and was transferred to the hospital on 1/7/26 before returning the next day. Resident R6 had diagnoses of high blood pressure, malnutrition, and hypokalemia and was transferred to the hospital before returning on 1/27/26. Resident R52 had diagnoses of abnormal weight loss, Down Syndrome, and need for assistance with personal care and was transferred to the hospital twice, returning on 1/14/26 after the second transfer. Resident R84 had diagnoses of heart failure, diabetes, and high blood pressure and was transferred to the hospital on 1/29/26 without returning at the time of review. Resident R89 had diagnoses of hypertension, diabetes, and right-sided hemiplegia and was transferred to the hospital without returning at the time of review. The facility also failed to notify the resident or the resident's representative of the bed-hold policy for five of five hospital transfers. The facility policy stated that written notice of the bed-hold policy would be provided within 24 hours of an emergency transfer, but the clinical records for R2, R6, R52, R84, and R89 did not contain documented evidence that this notice was provided at the time of transfer. During interview, the DON confirmed both the failure to communicate the required transfer information and the failure to provide bed-hold policy notification.
Failure to Notify Physician of Elevated Blood Glucose and Follow Weight Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care for residents with diabetes when it did not ensure physician notification for repeated elevated capillary blood glucose readings for three residents. Resident R2 had diagnoses including heart failure, diabetes, and dementia, and had an order for accuchecks twice daily without parameters for when to contact the physician. The record showed multiple blood glucose readings ranging from 352 mg/dL to 487 mg/dL, but progress notes from 1/11/26 through 2/17/26 did not document that the physician was notified of these elevated results. During interview, an RN stated the physician would be notified of those readings and confirmed the order lacked notification parameters and the record did not show physician notification. Resident R4 had diagnoses including high blood pressure, diabetes, and hemiplegia, and also had an order for accuchecks twice daily without parameters for physician notification. The resident had elevated blood glucose readings of 381 mg/dL, 423 mg/dL, and 376 mg/dL, but progress notes from 1/1/26 through 2/10/26 did not document that the physician was notified of those results. The RN interviewed stated the physician would be notified of those blood sugar readings and confirmed the order lacked parameters and the record did not show physician notification. Resident R60 had diagnoses including hypertension, diabetes, and COPD, and had an order for glucometer checks with Humalog administration with meals, also without parameters for when to contact the physician. The record showed blood glucose readings of 469 mg/dL, 427 mg/dL, 437 mg/dL, and 460 mg/dL, but progress notes from 2/7/26 through 2/10/26 did not document physician notification. An RN confirmed the order lacked notification parameters and stated the physician should be notified on any reading over 400. In addition, Resident R16 had an order to be weighed twice weekly for lymphedema, but the weight record showed gaps and weights were only obtained on several dates rather than consistently on Tuesdays and Fridays as ordered.
Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure residents were assessed and provided necessary treatment and services, consistent with professional standards of practice, for pressure ulcers for three residents. Resident R3, who had diagnoses of diabetes mellitus, unspecified dementia, and autistic disorder, had a coccyx Stage 2 pressure ulcer documented in a wound progress note, but the record noted no measurements at admission and the first measurement was not documented until several days later. Resident R9, who had diagnoses of diabetes mellitus, hypertension, and anxiety disorder, had a sacrum Stage 3 pressure ulcer documented in a wound progress note, with no measurements at admission and the first measurement not documented until several days later. Resident R55, who had diagnoses of high blood pressure, hyperlipidemia, and dementia, had a Stage 3 pressure ulcer identified on the MDS and a physician order for right buttock cleansing and Calmoseptine every shift and as needed when soiled. The January and February 2026 TARs showed multiple shifts where the treatment was not signed off as completed or refused, and the clinical record did not contain documentation of the ordered weekly skin assessments for several weeks. Facility staff confirmed the failure to ensure assessment, monitoring, and treatment consistent with professional standards of practice for the pressure ulcer care provided to these residents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for five residents who had physician orders for oxygen therapy and/or nebulizer treatments. Facility policy required oxygen tubing and masks/cannulas to be changed weekly and as needed if soiled or contaminated, nebulizer tubing and delivery devices to be changed every 72 hours or per policy and as needed if soiled or contaminated, and delivery devices to be kept covered in a plastic bag when not in use. Resident R2 had diagnoses including heart failure, diabetes, and dementia, and was ordered oxygen via nasal cannula 3 to 4 liters per minute every shift for COPD, with oxygen tubing and filter to be changed weekly. During observation, R2 was in bed with oxygen in use; the oxygen concentrator was beside the bed, the oxygen tubing was dated 1/28/26, and the nebulizer tubing was dated 1/1/26 and was not stored in a bag when not in use. Resident R29 had diagnoses including hypertension, anxiety, and respiratory failure, and was ordered oxygen as needed to keep oxygen saturations above 90 percent with tubing and filters to be changed weekly; during observation, R29 was in bed with oxygen in use and the oxygen tubing was dated 1/28/26. Resident R34 had COPD and was ordered ipratropium-albuterol via nebulizer every 6 hours for wheezing; during observation, the nebulizer was sitting on the bedside table and not stored in a bag, which was confirmed by an RN. Resident R60 had hypertension, diabetes, and COPD and was ordered oxygen at 2 liters per minute as needed; during observation, the oxygen tubing was not labeled with a date, which was confirmed by an RN. Resident R65 had diabetes, dementia, and respiratory failure, with orders for oxygen via nasal cannula every shift for COPD, weekly oxygen tubing and filter changes, PRN albuterol nebulization, and weekly nebulizer tubing and filter changes; during observation, R65 was in bed with oxygen in use, the oxygen tubing was dated 1/28/26, the nebulizer tubing was dated 1/28/26, and it was not stored in a bag when not in use. An RN and the President of Operations confirmed the facility failed to provide appropriate respiratory care for these residents.
Unsecured treatment cart, lab supplies, and unlabeled medications
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use on the 4th Floor, and it also failed to properly secure lab work supplies on that unit. During an observation, the 4th Floor Treatment Cart was seen at the nurses station unlocked and unattended. A plastic portable caddy at the 4th Floor nurses station was also observed unsecured and unattended, and it contained twelve 25 gauge blood collection needle and tubing sets, seven 22 gauge needles, and four 21 gauge needles. An RN confirmed that the treatment cart and lab work supplies were not properly secured while not in use. The facility also failed to properly store medication in two medication carts. On the Grandview Medication Cart, two Lantus Insulin Pens were observed with no open or expiration date noted and no resident name on the pens. On the Riverview Medication Cart, three medication cups containing two light colored pills each were found in the top drawer; the pills were unmarked, unlabeled, and unsecured. An LPN confirmed the insulin pens and the unlabeled pills during the cart reviews. The 4th Floor Treatment Cart was again observed later in the hallway unlocked and unattended, and another LPN confirmed that it was unlocked and unattended.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The former NHA and DON did not effectively manage the facility to ensure proper supervision was provided for residents at high risk for elopement, resulting in a resident elopement that created an immediate jeopardy situation. The report states that the NHA’s job description required oversight of facility operations, resident rounds, and ensuring resident incidents and reportable events were handled appropriately, while the DON was responsible for directing nursing operations, monitoring for allegations of abuse or neglect, overseeing resident incidents daily, and reporting unusual occurrences promptly to the NHA or state agency. Based on the findings, the facility failed to effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required. The report states that this failure resulted in a resident elopement and that the facility failed to provide the fundamental principles that apply to treatment and care provided to facility residents, including ensuring residents received treatment and care in accordance with professional standards of practice and facility policies.
Missing Current Hospice Documentation
Penalty
Summary
The facility failed to maintain hospice documentation for three residents receiving hospice services. For Resident R9, the clinical record showed diagnoses of diabetes mellitus, hypertension, and anxiety disorder, and a physician order dated 1/13/26 for hospice services, but the record lacked evidence of hospice agency communication and there was no hospice binder with a current plan of care or hospice documentation. During interview, the president of Operations confirmed that Resident R9’s record lacked hospice communication and the required hospice binder. For Resident R23, the record showed diagnoses of high blood pressure, hyperlipidemia, and depression, and a physician order dated 1/2/26 indicating the resident was admitted to hospice services on 11/6/23 for end stage cardiac disease. However, the only hospice certification and plan of care found in the record was dated 12/30/24 - 2/27/25, and no recent hospice plan of care was present. For Resident R65, the record showed diagnoses of diabetes, dementia, and respiratory failure, and a physician order dated 6/27/24 for hospice services for COPD. The hospice communication binder contained a last plan of care dated 4/23/25 - 6/21/25 and the last documented hospice visit dated 10/1/25, but no current plan of care or hospice documentation was available. An RN confirmed that Resident R23 and Resident R65 lacked current hospice documentation.
Hand Hygiene, Wound Care, Refrigerator Monitoring, and Lab Result Tracking Failures
Penalty
Summary
The facility failed to ensure proper hand hygiene on six nursing units because hand sanitizer dispensers were empty and hand soap was unavailable in multiple resident restrooms. During observation, three of three hand sanitizer dispensers on the Fourth floor were empty, and later rounds found no hand sanitizer in 32 of 32 wall dispensers across Lilac Lane, Rosewood, Vineyard, Riverview, Hilltop, and Grandview. In addition, 17 of 62 resident restrooms did not have hand soap. Staff interviews confirmed the shortage had been ongoing since the manufacturer recall in September 2025, and staff described using pocket-sized sanitizer, bottles on medication carts, or moving to another room to wash hands. Central Supply and Housekeeping were also observed without hand soap available in storage at the time of the survey. The facility failed to prevent cross contamination during a dressing change for a resident with diagnoses including high blood pressure, hemiplegia, and repeated falls. The resident had a physician order for sacral wound care to cleanse with soap and water, pat dry, apply medical grade honey, and cover with bordered gauze daily and as needed. During the observed dressing change, the RN did not perform hand hygiene before putting on clean gloves, after cleansing the wound, or before placing the new dressing on the wound. The RN later confirmed the observation. The facility failed to properly monitor a resident-owned refrigerator for another resident who had a small personal refrigerator on a bedside nightstand. The refrigerator contained boost, milk, apple cider, yogurt, salami, cream cheese, and salsa, but there was no temperature log showing daily monitoring and no thermometer inside the refrigerator. The facility also failed to monitor blood culture results for a resident who had been hospitalized and returned to the facility after blood cultures were completed in the hospital. Hospital documents showed the blood cultures were pending at discharge, but the resident's record did not include the final results. The RN Infection Preventionist stated the result had been missed and that the hospital would need to be contacted to obtain it.
Failure to Timely Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to timely offer and provide the COVID-19 vaccination for three residents, identified in the report as R16, R71, and R72. Facility policy stated that all residents would be offered vaccines to prevent infectious diseases unless medically contraindicated or already vaccinated, and that education about benefits and potential side effects would be provided and documented in the medical record, with refusals also documented. Review of the records showed that R16, who had diagnoses of high blood pressure, hyperlipidemia, and muscle weakness, had an MDS indicating the COVID-19 vaccination was not up to date, but the clinical record did not include documentation that the vaccine was offered, administered, or declined since admission. R71, who had diagnoses of high blood pressure, hyperlipidemia, and hemiplegia, also had an MDS coded as not up to date for COVID-19 vaccination. A progress note stated the resident was interested in the pneumococcal, COVID, and RSV vaccines but not all at the same time, and that Prevnar 20 was ordered, yet the record did not show that the COVID-19 vaccine was administered since admission. R72, who had diagnoses of high blood pressure, hyperlipidemia, and muscle weakness, had an MDS coded as not up to date for COVID-19 vaccination. A progress note documented education provided to the brother and nephew, with the nephew requesting vaccinations not all at the same time, and the flu vaccine was administered, but the record did not include documentation that the COVID-19 vaccine was administered since admission. The Infection Preventionist stated that COVID vaccines were offered and that the facility had switched pharmacies and was waiting to do a large COVID vaccine administration in February, and confirmed the facility failed to timely offer and provide the COVID-19 vaccination for the three residents.
Call Bells Not Accessible to Two Residents
Penalty
Summary
The facility failed to accommodate the call bell needs for two residents, R23 and R55, by leaving their call bells wrapped around the headboard and out of reach while they were lying in bed. Facility policy stated that staff will ensure the call light is within reach of the resident and secured as needed, and that the call system will be accessible while the resident is in bed or other sleeping accommodations. R23’s clinical record showed diagnoses of high blood pressure, hyperlipidemia, and depression, and R55’s record showed diagnoses of high blood pressure, hyperlipidemia, and dementia. During observations, both residents were seen in bed with their call bells not accessible for use, and a nurse aide confirmed that the call bells were not accessible and unavailable to the residents.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary psychotropic medication used without adequate indications for use. Resident R77 was admitted with diagnoses including hypertension, depression, and hyperlipidemia. The resident’s MDS dated 11/5/25 indicated antipsychotic medication use in the prior seven days and noted an indication. A physician order dated 8/5/25 directed risperidone 0.5 mg twice daily for agitation, and a psychiatric progress note dated 8/21/25 documented a diagnosis of dementia with other behavioral disturbance and to continue risperidone 0.5 mg twice daily. The resident’s care plan, revised on 11/24/25, identified potential for adverse reactions from psychotropic medication use and listed major depressive disease and dementia with other behavioral disturbance. A psychiatry progress note dated 1/8/26 documented follow-up for dementia with behavioral symptoms and psychotic features and continued risperidone at the current dose. During an interview on 2/12/26, an RN confirmed that Resident R77 did not have a diagnosis for the use of risperidone and that the facility failed to make certain the resident’s drug regimen was free from unnecessary drugs used without adequate indications for use.
Failure to Verify Credentials Before Hire
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to properly screen two newly hired personnel records before hire. Review of the facility’s Abuse, Neglect and Exploitation policy dated 12/11/25 showed that potential employees are to be screened for a history of abuse, neglect, exploitation, and misappropriation of resident property, and that background, reference, and credential checks are to be completed. Review of the License Verification policy dated 12/11/25 showed that personnel requiring a license or certification are to be verified through the appropriate issuing agency. Review of the personnel record for NA Employee E19 showed she was hired on 1/21/26, but her record did not include a completed certification check prior to the date of hire. Review of the personnel record for LPN Employee E20 showed he was hired on 1/21/26, but his record did not include a completed LPN license check prior to the date of hire. During an interview on 2/10/26 at 3:50 p.m., the Human Resources Employee E9 confirmed that the facility failed to properly screen NA Employee E19 and LPN Employee E20 by completing the certification/license check prior to hire.
Incorrect MDS Coding for Diuretic Use and Hospice Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected Resident R26’s status. Facility policy stated that resident assessments are to be accurate and reflective of the resident’s status at the time of assessment, and the RAI User’s Manual instructed that diuretic use and hospice care be coded when applicable. Review of R26’s clinical record showed the resident was admitted to the facility with diagnoses including anemia, dementia, and depression, and the MDS dated [DATE] did not select N0415G1 for diuretic use and coded O0110K1 hospice care as no. The record also showed a physician order for Lasix 40 mg by mouth daily for congestive heart failure, and the MAR for December 2025 indicated the resident received Lasix as ordered. In addition, a physician order dated 3/28/25 indicated hospice services beginning 3/18/25 with congestive heart failure as the admitting diagnosis. During interview, the RNAC confirmed that the MDS was coded incorrectly and should have reflected the resident’s diuretic therapy and hospice care.
Improper Indwelling Catheter Care and Incomplete Orders
Penalty
Summary
Appropriate care was not provided for the use of indwelling urinary catheters for two residents. Resident R34 was admitted with diagnoses including hyperlipidemia, anxiety, and urinary retention, and had a physician order for an 18 French Foley catheter with a 10 cc balloon. During an observation, R34 was lying in bed with a catheter connected to a drainage bag, and the drainage bag was not covered as required. An RN later confirmed that the drainage bag was not covered as required. Resident R88 was admitted with diagnoses including infection and inflammatory reaction due to an internal right hip prosthesis, anemia, and anxiety. During an observation, R88 was lying in bed with a catheter connected to a drainage bag, and the drainage bag was also not covered as required. An LPN confirmed this during interview. Review of R88's physician orders showed a catheter care order that did not specify the catheter type, size, diagnosis for use, or the amount of sterile water needed for balloon inflation, and an RN confirmed these omissions. The facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter for these two residents.
Failure to Provide Adequate Care for Midline Catheter
Penalty
Summary
Adequate treatment and care were not provided for a midline catheter for one resident with anemia, heart failure, and hypertension. Physician orders on 2/3/26 included 0.9% Sodium Chloride Solution at 100 ml/hr IV for 24 hours and a one-time midline placement for IV fluids. Progress notes documented the midline in the upper right arm as patent and without signs or symptoms of infection or infiltration on 2/5/26, 2/7/26, and 2/8/26. During an observation on 2/9/26, the resident was lying in bed with a midline in the right upper arm, and the cover dressing was dated 2/3/26. During an interview and observation on 12/12/26, an RN confirmed the midline was still in place and dated 2/3/26. On 2/12/26, an RN stated there were no orders for flushes or dressing changes and confirmed the facility failed to provide adequate treatment and care for the resident's midline catheter.
Failure to Complete Annual Nurse Aide Performance Evaluation
Penalty
Summary
The facility failed to complete an annual performance evaluation at least once every 12 months for one nurse aide, NA Employee E28. Review of the personnel record showed a hire date of 10/18/23 and that the most recent performance evaluation was completed on 1/8/24. During an interview on 2/12/25 at 12:11 a.m., the Human Resources Employee E9 confirmed that no performance evaluation had been conducted in 2025 for NA Employee E28, and the facility had not completed the required annual evaluation within the 12-month timeframe.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss for one resident reviewed, Resident R55. The facility policy on Dementia Care stated that residents with dementia should receive appropriate treatment and services through care plans that are achievable, individualized to symptomology and rate of progression, and person-centered to support dignity, autonomy, privacy, socialization, independence, choice, and safety. Resident R55 was admitted to the facility with diagnoses including high blood pressure, hyperlipidemia, and dementia. The resident’s MDS dated 12/27/25 showed a BIMS score of 8, indicating moderate cognitive impairment. Review of the care plan on 2/12/26 showed it did not indicate that the facility had developed and implemented an individualized person-centered care plan to address the resident’s dementia and cognitive loss. During interview, the RNAC confirmed that the facility failed to develop and implement such a care plan for Resident R55.
Missing Effective Communication Training for Two RNs
Penalty
Summary
The facility failed to provide Effective Communication training for two of five staff members, including RN Employee E29 and RN Employee E30. Review of the facility’s Training Requirements policy dated 12/11/25 showed that all new and existing staff, contractual staff, and volunteers were to receive training consistent with their roles, including Effective Communication, prior to independently providing services and annually as needed. Review of RN Employee E29’s personnel file showed a hire date of 2/1/24 and no Effective Communication training between 2/1/25 and 2/1/26. Review of RN Employee E30’s personnel file showed a hire date of 12/28/23 and no Effective Communication training between 12/28/24 and 12/28/25. During an interview on 2/12/25 at 12:11 a.m., Human Resources Employee E9 confirmed that the facility failed to provide the required training for these two staff members.
Failure to Provide Required Resident Rights Training
Penalty
Summary
The facility failed to provide training on Resident Rights for two of five staff members, Registered Nurse E29 and E30. Facility policy dated 12/11/25 stated that all staff, including those under contractual arrangement and volunteers, must receive training consistent with their roles, with training completed before independently providing services, annually, and as needed based on the facility assessment, and that training content includes Resident Rights. Review of E29's personnel file showed a hire date of 2/1/24 and no Resident Rights training between 2/1/25 and 2/1/26. Review of E30's personnel file showed a hire date of 12/28/23 and no Resident Rights training between 12/28/24 and 12/28/25. During an interview on 2/12/25 at 12:11 a.m., Human Resources Employee E9 confirmed that the facility failed to provide Resident Rights training for the two staff members as required.
Missing Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide required Abuse, Neglect, and Exploitation training for two of five staff members, including RN Employee E29 and E30. Review of the facility’s Training Requirements policy showed that all staff are to receive training as part of an effective training program, with Abuse, Neglect, and Exploitation Prevention included as a minimum topic and training required before independently providing services and annually thereafter. Review of RN E29’s personnel file showed a hire date of 2/1/24 and no Abuse, Neglect, and Exploitation training between 2/1/25 and 2/1/26. Review of RN E30’s personnel file showed a hire date of 12/28/23 and no Abuse, Neglect, and Exploitation training between 12/28/24 and 12/28/25. During interview, Human Resources Employee E9 confirmed the facility failed to provide this training for two of five staff members as required.
Missing Required QAPI Training for Two RNs
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for two of five staff members, Registered Nurse E29 and RN E30. Review of the facility’s Training Requirements policy dated 12/11/25 showed that all new and existing staff, contractual staff, and volunteers were to receive training consistent with their roles, including QAPI training, prior to independently providing services and annually as needed. Review of E29’s personnel file showed a hire date of 2/1/24 and no documented QAPI training between 2/1/25 and 2/1/26. Review of E30’s personnel file showed a hire date of 12/28/23 and no documented QAPI training between 12/28/24 and 12/28/25. During an interview on 2/12/25 at 12:11 a.m., Human Resources Employee E9 confirmed that the facility failed to provide QAPI training for these two staff members as required.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide required Infection Control training for two of five staff members, Registered Nurse E29 and Registered Nurse E30. Review of the facility’s Training Requirements policy dated 12/11/25 showed that all staff must receive training on the Infection Prevention and Control Program prior to independently providing services, annually, and as needed based on the facility assessment. Review of E29’s personnel file showed a hire date of 2/1/24 and no Infection Control training between 2/1/25 and 2/1/26. Review of E30’s personnel file showed a hire date of 12/28/23 and no Infection Control training between 12/28/24 and 12/28/25. During an interview on 2/12/25 at 12:11 a.m., Human Resources Employee E9 confirmed that the facility failed to provide Infection Control training for these two staff members as required.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to provide Compliance and Ethics training for two of five staff members, including RN Employee E29 and RN Employee E30. Review of the facility's Training Requirements policy dated 12/11/25 showed that all staff, including those under contractual arrangement and volunteers, were required to receive training consistent with their roles, with training to be completed prior to independently providing services, annually, and as needed based on the facility assessment. Review of RN Employee E29's personnel file showed a hire date of 2/1/24 and no Compliance and Ethics training documented between 2/1/25 and 2/1/26. Review of RN Employee E30's personnel file showed a hire date of 12/28/23 and no Compliance and Ethics training documented between 12/28/24 and 12/28/25. During an interview on 2/12/25 at 12:11 a.m., Human Resources Employee E9 confirmed that the facility failed to provide the required training for these two staff members.
Missing Behavioral Health Training for RN Staff
Penalty
Summary
Behavioral Health training was not provided for two RN staff members, Employee E29 and Employee E30, as required by facility policy and the facility assessment. The facility policy on Training Requirements stated that all staff must receive training consistent with their roles, including Behavioral Health, prior to independently providing services, annually, and as necessary based on the facility assessment. Review of Employee E29’s personnel file showed a hire date of 2/1/24 and no Behavioral Health training between 2/1/25 and 2/1/26. Review of Employee E30’s personnel file showed a hire date of 12/28/23 and no Behavioral Health training between 12/28/24 and 12/28/25. During interview, Human Resources Employee E9 confirmed the facility failed to provide Behavioral Health training for these two of five staff members as required.
Failure to Maintain Safe Room Temperatures and Monitor Residents for Hypothermia
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within the facility’s own policy range of 71–81°F and to monitor and assess residents for hypothermia when the heating system was not functioning properly. The facility’s Safe and Homelike Environment policy required provision of a safe, comfortable environment, and the Loss of Heating or Cooling policy required immediate actions to maintain temperatures between 71–81°F, including monitoring temperatures, increasing rounding, layering clothing, providing extra blankets and warm foods/fluids, and monitoring for signs of hypothermia with physician notification as needed. The Nursing Home Administrator (NHA) reported being aware that the heat was not working the prior week and that a heating company came on a Saturday to install a control board, later determining that an additional gas valve was needed. The NHA presented audits of only 5–6 random rooms per floor and did not have staff check all resident rooms or assess/interview residents to ensure their needs were being met. Observations on the third and fourth floors showed that the heating system was not working at full capability, with room temperatures ranging from 68°F to 81°F and some residents stating they were cold while others felt comfortable. Some windows were observed not fully closed, and some residents reported they had opened their windows. Although residents had extra blankets and clothing, all interviewed residents stated that no staff member had offered extra blankets or warm fluids. Subsequent facility-provided temperature audits documented that, during early-morning checks, the vast majority of rooms on both the third and fourth floors were below 71°F, with the lowest recorded temperatures at 63°F on the third floor and 58.6°F on the fourth floor. During a tour, surveyors noted that the third and fourth floors felt cold overall, and spot temperature checks with maintenance staff showed multiple rooms in the upper 60s to about 70°F. Multiple residents were observed in bed with three or four blankets, winter coats, or tassel caps, and several reported feeling cold, especially at night or when getting up. One resident stated her legs were cold and that her window had been cracked open the previous night; another said he had been cold and that it gets very cold at night; others reported that their rooms were cold or that they had been cold but were warm at the time due to multiple blankets. Few residents were seen in hallways, and those present were covered with blankets. A nurse stated that residents complained of being cold and that she had brought in two bags of blankets to keep them warm. Record review for selected residents showed that there were no physician orders to monitor for hypothermia or to monitor body temperatures in response to the environmental issue, despite the facility’s policy requiring monitoring for signs of hypothermia when heating is compromised. For one resident, the last documented temperature was from early in the month; for another, the last temperature was several days prior; and for a third, the last temperature was from the previous month. The NHA confirmed that the heaters were not working at 100%, that the facility had noticed the problem in the middle of the prior week, and that repairs were in progress. The NHA also confirmed that the facility failed to ensure comfortable air temperature levels between 71–81°F and failed to monitor and assess all residents for hypothermia, resulting in an Immediate Jeopardy situation for all 82 residents.
Removal Plan
- Complete heating system repair and continue ongoing monitoring of system performance.
- Conduct room temperature audits in every resident room every two hours until all resident rooms are at 71°F or higher, then once every four hours daily for seven days, weekly for three weeks, then monthly for three months.
- Include in temperature audits ensuring windows are closed and residents are offered plastic covering for windows.
- Evaluate all residents for signs and symptoms of hypothermia, including residents unable to independently express needs and residents with a temperature over the last three days and/or during whole house audit of 97.6°F or lower.
- Address any identified concerns immediately with individualized interventions and place orders for ongoing monitoring as needed.
- Document resident temperatures in the weights/vitals section of the electronic medical record and document hypothermia evaluation in progress notes.
- Conduct an audit of resident observations for cold intolerance, distress, or changes in condition related to temperature in every resident room every shift daily for seven days, weekly for three weeks, then monthly for three months.
- Ask interviewable residents about comfort level and offer interventions as needed.
- Evaluate non-interviewable residents for observable signs of discomfort related to temperature.
- Educate nursing staff (including agency) on signs and symptoms of hypothermia, risk factors, interventions to prevent hypothermia, comfort measures, and appropriate response when signs/symptoms are identified.
- Educate nursing assistants on non-clinical signs and symptoms of hypothermia and to alert a nurse if observed.
- Complete staff education; staff educated by phone/email to sign education prior to next working shift; reinforce education as needed.
- Provide additional blankets, layering, and environmental adjustments as needed.
- Offer room relocation as appropriate to maintain resident comfort.
- Implement a plan to utilize outside resources as necessary to maintain safe air temperatures during future weather events or mechanical issues, including an updated rental company in place.
- Review relevant policies and procedures related to environmental safety, resident monitoring, and emergency response.
- Update policies as indicated based on audit findings and QAPI review.
- Report audit findings, trends, and corrective actions to the QAPI committee; QAPI to evaluate effectiveness and recommend changes as needed.
- Apply plastic coverings to every resident room and hallway window in resident care areas to prevent drafts.
- Clarify/register controls after identifying some knobs on registers were turned off to prevent inadvertent turning off of heat.
- Have heating vendor send a technician back to ensure correct functionality and further explore the system for any additional needed corrections and complete repairs as soon as possible pending parts/resources.
- Install rental one-ton heating units and rent for at least one week.
- Order and install additional rental heating units.
- For rooms reading under 71°F with a laser thermometer, re-check using a room air thermometer and verify temperatures above 71°F.
- Order air thermometers for each room.
Improper Containment and Disposal of Garbage in Outdoor Dumpster Area
Penalty
Summary
The facility failed to properly contain and dispose of garbage and refuse in accordance with its own policy, which requires sufficient receptacles, a clean surrounding area, and prevention of debris accumulation and insect/rodent attractions, including not allowing garbage to accumulate outside the dumpster. During an observation, the outdoor trash compactor area was found to have two shopping carts, an oversized chair, many empty cardboard boxes, and an uncountable number of filled garbage bags sitting around the dumpster instead of being properly contained. In an interview, the Nursing Home Administrator confirmed that trash and debris were collecting in the disposal area and acknowledged that the facility failed to properly contain and dispose of garbage in the outside dumpster area to prevent potential rodent and insect infestation. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on environmental sanitation and waste management practices in the outdoor trash disposal area, as cited under 28 Pa. Code 201.18(b)(3) Management.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to determine whether it was safe for a resident to self-administer medications before leaving medications at the bedside. Facility policy dated 12/11/25 stated that residents may only self-administer medications after the interdisciplinary team determines which medications can be self-administered safely. The clinical record showed that the resident was admitted on an unspecified date and had diagnoses including hypertension, anemia, and dementia, with a BIMS score of 10 indicating moderate cognitive impairment. Despite this, there was no documented self-administration assessment, no physician order authorizing self-administration, and no care plan addressing self-administration of medications. During an observation, the resident was found lying in bed with a clear medication cup containing four pills (one white, one brown, one peach, and one black) on the bedside table, with no nurse present in the room. An RN acknowledged that it was an oversight and confirmed the presence of the medication cup at the bedside. Review of the resident’s physician orders and care plan did not show any authorization or planning for self-administration of medications, and review of the clinical record did not reveal a completed self-administration assessment. The DON confirmed that the facility failed to determine whether it was safe for this resident to self-administer medications.
Unattended Medication Carts Exposed Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information by leaving three of four medication carts unattended in hallways with computer screens open displaying identifiable resident information. Facility policy titled HIPAA Security Measures, dated 12/11/25, required the implementation of reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of residents' identifiable information and electronic records. Despite this policy, surveyors observed the Vineyard and Rosewood medication carts on 1/29/26 sitting beside each other in a hallway, unattended, with computer screens open and visible to any passerby, displaying residents' personal and confidential information. During interviews conducted immediately following these observations, an LPN (Employee E1) confirmed that the Vineyard cart computer screen had been left unattended and open with identifiable information visible, and an RN (Employee E2) similarly confirmed the same issue with the Rosewood cart. On 1/31/26, surveyors again observed the Rosewood 2 medication cart left unattended in the hallway with its computer screen open and displaying identifiable resident information. An RN (Employee E3) stated they had been in a resident room and confirmed that the Rosewood 2 cart was left unattended with confidential information visible. The Nursing Home Administrator later confirmed that the facility failed to maintain the confidentiality of residents' medical information on the Vineyard, Rosewood, and Rosewood 2 medication carts, as required by applicable Pennsylvania regulations regarding licensee responsibility, resident rights, medical records, and nursing services.
Failure to Clear Snow and Maintain Safe Parking Lots and Exits
Penalty
Summary
The facility failed to ensure that the outside environment was free of accident hazards and did not provide adequate supervision to prevent accidents related to snow and ice. Three days after a snowstorm, surveyors observed that the front parking lot, which is used for visitors, transport, and ambulances, was largely impassable. Only one entrance was plowed, and the exit was not plowed, with snow impeding the ability to leave the lot quickly. Sidewalks leading to the building were not shoveled. A second parking area was completely covered with snow, had not been plowed, and vehicles were stuck in the lot. A family member concern documented that the area was a “disaster” with snow, stating that you could not get in or out. During interviews, the NHA reported that the contracted snow removal company never arrived during or after the snowstorm to maintain the grounds and that, as of the survey date, the facility was still in the process of finding a contractor to remove the snow and clear the remaining parking lot and entrance. The NHA stated that only a portion of the lot had been cleared by the local road crew. Later observations showed that the walkways to the Virginia Ave emergency exit and the courtyard emergency exit were not shoveled; although both doors opened, the surrounding areas were not clear for walking. The NHA confirmed that the facility failed to ensure the outside environment was free of potential hazards, failed to evaluate the snow hazard, and failed to implement a plan for snow removal for both parking lots and for two of three exits, several days after the snowstorm ended.
Unlocked and Unattended Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to secure multiple medication carts in accordance with its own Medication Storage policy and accepted professional standards. The policy dated 12/11/25 requires that all drugs and biologicals be stored in locked compartments, including medication carts, and specifies that during a medication pass, medications must either be under the direct observation of the person administering them or locked in the cart. Surveyors observed that these requirements were not followed for three of four medication carts. On one observation, the Vineyard and Rosewood medication carts were found sitting in the hallway next to each other, both unlocked and unattended. An LPN confirmed that the Vineyard cart was unlocked and unattended, and an RN confirmed the same for the Rosewood cart, acknowledging that the facility failed to properly secure the carts while not in use. On another observation, the Rosewood 2 medication cart was also seen in the hallway, unlocked and unattended, while the responsible RN reported being in a resident room at the time and confirmed the cart was not secured. The Nursing Home Administrator later confirmed that the facility failed to properly secure three of four medication carts (Vineyard, Rosewood, and Rosewood 2), as required by facility policy and applicable state regulations.
Failure to Maintain Safe Temperatures and Monitor Residents for Hypothermia
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to ensure that comfortable air temperature levels, defined as between 71–81 degrees Fahrenheit, were maintained throughout the facility for all residents. Job descriptions for both the NHA and DON specified responsibilities that included leading and directing facility operations in accordance with federal and state regulations, performing rounds to observe residents and ensure their needs were met, and fulfilling responsibilities during implementation or activation of the facility’s emergency plan. Despite these defined duties, the facility did not provide air temperatures within the required range for any of the 82 residents. In addition to the temperature issue, the NHA and DON failed to ensure that all residents were monitored and assessed for hypothermia, which is described in the report as a life-threatening medical emergency occurring when the body loses heat faster than it can produce it. This lack of monitoring and assessment applied to all 82 residents in the facility. Based on review of job descriptions, clinical records, observations, and staff interviews, surveyors determined that these failures constituted noncompliance with federal and state guidelines and regulations and created an Immediate Jeopardy situation affecting all residents. During an interview, the NHA was informed of these failures and the resulting Immediate Jeopardy determination.
Kitchen Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to properly maintain kitchen equipment in a sanitary condition, creating the potential for cross contamination in the main kitchen. Facility policy for sanitation inspections dated 1/7/25 stated that food service areas are to be kept clean, sanitary, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. During an observation of the walk-in cooler in the main kitchen with the Certified Dietary Manager, the cold air condenser unit was found to have a build-up of dust, grime, and dark colored debris around the fan covers and on the ceiling immediately forward of the fans. The Certified Dietary Manager confirmed the observation and acknowledged that the walk-in cooler had not been properly maintained in a sanitary condition.
Improper Garbage Disposal and Dumpster Area Housekeeping
Penalty
Summary
The facility failed to properly contain and dispose of garbage in the outside dumpster area, with trash and debris collecting in the disposal area. Review of the facility policy on Disposal of Garbage and Refuse, dated 1/7/25, stated that kitchen garbage and refuse shall be disposed of, dumpsters shall be kept covered when not being loaded, the surrounding area shall be kept clean to minimize debris and insect or rodent attractions, and garbage should not accumulate or be left outside the dumpster. During an observation and interview of the outdoor trash compactor on 9/15/25 at 10:00 a.m., the Certified Dietary Manager confirmed that trash and debris were present in the disposal area, and the facility failed to properly contain and dispose of garbage in the outside dumpster area to prevent potential rodent and insect infestation.
Failure to Maintain Resident Dignity During Catheter Care and Dining
Penalty
Summary
Resident dignity was not maintained for two residents with indwelling Foley catheters. Resident R18 had diagnoses including diabetes, chronic pain, and atrial fibrillation, and a physician order dated 6/5/25 indicated a Foley catheter related to neuromuscular dysfunction of the bladder. During an observation on 9/15/25, at 10:37 a.m., R18's catheter drainage bag was seen hanging on the bed frame without a dignity/privacy bag. An LPN confirmed at 10:40 a.m. that the drainage bag did not have a privacy cover and that the facility failed to ensure care was provided in a manner that maintained R18's dignity. Resident R51 had diagnoses including high blood pressure, depression, and neurogenic bladder, and the MDS coded an indwelling catheter. A physician order dated 2/26/25 directed that the Foley drainage bag be kept covered at all times. During an observation on 9/15/25, at 11:35 a.m., R51's catheter drainage bag was observed hanging on the bed frame without a dignity/privacy bag. An RN confirmed at 11:37 a.m. that the drainage bag did not have a privacy cover and that the facility failed to ensure care was provided in a manner that maintained R51's dignity. In addition, Resident R67, who was coded as dependent for eating and had orders to assist to dine, was observed on 9/17/25 at 1:40 p.m. sitting at the nurse's station with lunch sitting on top of the nurse's station and not served. At 1:45 p.m., an RN stated, "Oh, I'll feed him now," and then fed the resident; the food was found to be cold. The facility also served meals on foam plates with plastic silverware, and residents and a resident representative reported this was regular practice. The Dietary Manager stated the facility had been experiencing shortages of plates, bowls, plate warmers, and silverware since August 2025, and the Nursing Home Administrator confirmed the facility failed to provide a dignified dining experience for three of six months by serving on disposable dinnerware.
Inadequate Linens and Unclean Shower Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment and failed to accommodate proper linen needs on the third and fourth floors. During a tour, the clean linen racks on the fourth floor and on the third floor were found with inadequate and damaged linens, including ripped towels being used as washcloths, ripped bath blankets, torn sheets, and no towels or pillowcases on one rack. Staff interviews confirmed the shortage, with an LPN and multiple NAs stating there was not enough linen for morning care and that they had to use whatever was available, including wipes, pillowcases, bath blankets, and torn washcloths. One NA stated the problem had been ongoing for weeks to at least a month and that baths or showers could not be given because there were not enough supplies. The third floor environment also had cleanliness and maintenance concerns. Resident R45's privacy curtain was observed to be soiled on the lower half, and an RN confirmed the curtain's condition. A room that had been cleaned for a new admission still had a dirty urinal with dark amber stains in the bathroom. In the third floor shower room, surveyors observed two mechanical lifts, an empty linen cart, a shower chair, and a bedside commode in the whirlpool tub room, along with a broken wall tile, debris on the floor of two shower stalls, yellow discoloration on all shower stall floors, rust on the ceiling, peeling ceiling material near a light fixture, and a small hole in the ceiling where light from the floor above was visible. An open bottle of white distilled vinegar was also left on the floor with the cap beside it. The NHA confirmed the facility failed to provide a clean, safe, homelike environment in the room and shower room and failed to accommodate proper linen needs on both units.
Infection Control Failures With Hand Hygiene, Dressing Change, and COVID Surveillance
Penalty
Summary
Failure to ensure proper hand hygiene was identified during observation and interview. Facility policy stated that staff were to perform hand hygiene, including before putting on gloves and immediately after removing them, and that gloves did not replace hand hygiene. On 9/15/25, seven of seven hand sanitizer stations on the Third and Fourth floors were observed to be empty, and on 9/16/25 the stations remained empty. A RN confirmed the dispensers had been empty for weeks, and the NHA stated the facility had removed the recalled sanitizer and had not yet refilled the dispensers with another product. Failure to prevent cross contamination occurred during a dressing change for a resident with high blood pressure, diabetes, and venous insufficiency. The resident’s physician orders directed cleansing the legs, applying triamcinolone cream, ammonium lactate cream, Adaptic over open areas, and securing with Kerlix every three days. During observation, an LPN performed the dressing change while changing gloves multiple times but did not wash hands between steps, did not wash hands after glove removal, and did not wash hands before leaving the room. The LPN also removed scissors from a pocket and used them without cleaning them first. The LPN later confirmed that no hand washing was completed during or after the dressing change and that the scissors were not cleaned prior to use. The infection prevention and control program was also found deficient in surveillance and outbreak response. Facility policy stated that surveillance tools were used to identify infections, outbreaks, employee infection, adherence to infection prevention practices, and unusual pathogens. Review of monthly surveillance records showed that floor mapping was not available for July, August, and September 2025, and the DON confirmed the facility could not produce those documents. In addition, a resident tested positive for COVID-19, and the DON stated an RN had tested positive and did not notify the facility until the next day. The DON reported the facility did not conduct contact tracing or test exposed residents or staff during the exposure period, and testing of residents on the third floor did not occur until several days later. During observation, the positive resident was in a room with two staff members wearing masks but no eye protection, there was no proper signage for precautions, and the roommate was not wearing source control.
Failure to Verify Safe Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was safe for three residents. The facility policy dated 1/7/25 stated residents may self-administer medications only after evaluation by the interdisciplinary team and approval by the medical provider, with a provider order authorizing self-administration if the resident is able to do so safely. However, review of the clinical records for Residents R4, R26, and R61 failed to show physician orders authorizing self-administration, and their care plans did not address self-administration of medications. Resident R4 had diagnoses including COPD, anxiety, and depression, and a tube of zinc oxide ointment was observed on the bedside stand. Resident R26 had diagnoses including diabetes, stroke, and high blood pressure, and two tubes of medication, mupirocin cream and miconazole cream, were observed on the window sill. Resident R61 had diagnoses including high blood pressure, diabetes, and dementia, and a medication cup with a brown pill was observed on the bedside table; the resident stated they did not want to take the pill. During the tour, RN E10 confirmed the medications at bedside for all three residents and confirmed the absence of a physician order or care plan for self-administration.
Unnecessary Psychotropic Medications Not Properly Reviewed
Penalty
Summary
The facility failed to ensure that medication regimens were free from potentially unnecessary psychotropic medications for four residents. Review of facility policy showed that psychotropic medications are to be clinically indicated and necessary, and that medication regimen reviews are to be completed monthly with pharmacist recommendations reviewed and addressed by the DON and attending physician. Survey review found that the physician responses to several pharmacist recommendations were not documented in the clinical records for the residents involved. For one resident with dementia, bipolar disorder, and depression, the record showed bupropion ER 300 mg daily and Lamictal 25 mg twice daily for bipolar disorder. A psychiatric note recommended a gradual dose reduction for bupropion from 300 mg to 150 mg, but the record did not show that the physician addressed and signed the pharmacist review or that the recommended GDR was completed. For another resident with adjustment disorder, pseudobulbar affect, and vascular dementia, Xanax 0.25 mg every 12 hours as needed was ordered without a 14-day stop date or documented physician rationale for use beyond 14 days, and the resident received the PRN Xanax six times in September 2025. For a third resident with dementia, heart failure, and diabetes, the record did not include a completed physician response to the pharmacist’s May 2025 recommendations. The pharmacist noted hydroxyzine 10 mg at bedtime as a psychotropic medication and stated that a GDR must be attempted unless clinically contraindicated, but the physician did not address and sign the review. For a fourth resident with dementia, heart failure, and high blood pressure, the record also lacked a written physician response to the pharmacist’s July 2025 recommendations. The pharmacist identified Buspar 7.5 mg twice daily as a psychotropic medication and noted that a GDR must be attempted unless clinically contraindicated, but the physician did not address and sign the review.
Failure to Obtain Ordered Weights for Residents With Weight Loss
Penalty
Summary
The facility failed to properly monitor residents' weight and nutrition status by not obtaining ordered weights for four of four residents reviewed. The facility policy on Weight Monitoring, dated 1/7/25, stated that all residents would be monitored to maintain acceptable nutritional status and that a weight monitoring schedule would be developed upon admission. Review of the clinical records showed that Resident R7, who had diagnoses including high blood pressure, muscle weakness, and need for assistance with personal care, had a physician order on 8/20/25 for weekly weights for four weeks due to weight loss, but no documented weights were found on 9/3/25 and 9/10/25. Resident R10, with ESRD, aphasia, and hemiplegia, had a physician order on 8/18/25 for weekly post-dialysis weights every Wednesday, but no documented weights were found on 8/27/25 and 9/10/25. Resident R29, who had a right femur fracture, dementia, and venous insufficiency, had an MDS indicating weight loss of 5% or more in the last month or 10% or more in the last 6 months, and a physician order on 8/20/25 for weekly weights, but weights were not documented on 8/22/25, 9/5/25, and 9/12/25; the weight summary showed a 17.4 lb (12%) loss since 7/8/25. Resident R56, with abnormal weight loss, Down Syndrome, and need for assistance with personal care, had a physician order on 8/14/25 for weekly weights for four weeks due to weight loss, but no documented weight was found for 9/4/25. During interview, the RD confirmed the facility failed to obtain the ordered weights for Residents R29, R7, R10, and R56.
Failure to Provide Proper Nebulizer Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents who had physician orders for Ipratropium-Albuterol inhalation solution via nebulizer. Resident R4 had diagnoses of COPD, anxiety, and depression, and on observation the nebulizer was on the stand, not dated, and not stored in a bag as required by facility policy. Resident R4 stated they used the nebulizer multiple times a day, and an LPN confirmed the nebulizer was not dated or stored in a bag. Resident R10 had diagnoses of ESRD, aphasia, and hemiplegia, and a physician order for nebulizer treatment every 6 hours as needed for shortness of breath. On observation, the nebulizer machine was on the bedside table with the facemask on the table and not stored in a bag while not in use, and the connecting tubing was dated 7/8. Resident R17 had diagnoses of high blood pressure, multiple sclerosis, and respiratory failure, and a physician order for nebulizer treatment as needed for shortness of breath or wheezing. On observation, the nebulizer machine was on the bedside stand with the handheld nebulizer beside it, not stored in a bag, and the tubing was not dated. Resident R17 stated they had the same mouthpiece for weeks, and an RN confirmed the nebulizer was not stored in a bag and the tubing was not dated.
Incomplete Dialysis Communication and Missing Care Plan
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents receiving hemodialysis. Resident R10 had ESRD, aphasia, and hemiplegia, and a physician order required assessment prior to dialysis, vital signs, completion of the dialysis sheet, and sending the folder with the resident every Monday, Wednesday, and Friday. The clinical record did not include complete dialysis communication forms for 9/1/25, 9/8/25, and 9/12/25, and no communication form was located for 9/5/25. RN E2 confirmed the missing and incomplete forms during interview. Resident R34 had diagnoses including metabolic encephalopathy, anemia, and heart failure, and a readmission order indicated dialysis on Monday, Wednesday, and Friday, later revised to include a 10:00 a.m. chair time. The resident’s care plan directed nursing staff to provide a communication folder to the dialysis provider each treatment day and to call for a report if none was received, but the record did not include complete communication forms for 9/12/25 and no forms were located for 9/10/25, 9/15/25, or 9/17/25. Resident R72 had ESRD, hypertension, and diabetes, with orders for dialysis on Monday, Wednesday, and Friday, pickup at 12:00 p.m., chair time at 1:00 p.m., and an external hemodialysis catheter in the right chest with dry dressing and no end cap changes every shift. The current care plan failed to include dialysis or the external catheter, and the record did not include complete communication forms for 9/15/25 and 9/17/25. The DON confirmed the care plan omission and the incomplete dialysis communication.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Rehab And Health | 2.7 mi | ★★★★★ | 53 | 1 |
| Providence Health & Rehab Center | 3.9 mi | ★★★★★ | 44 | 1 |
| Concordia At Villa St Joseph | 5 mi | ★★★★★ | 16 | 0 |
| Beaver Healthcare And Rehabilitation Center | 6.6 mi | ★★★★★ | 1 | 0 |
| Sherwood Oaks | 8.3 mi | ★★★★★ | 8 | 1 |
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