Rochester Residence And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, Pennsylvania.
- Location
- 174 Virginia Avenue, Rochester, Pennsylvania 15074
- CMS Provider Number
- 395751
- Inspections on file
- 44
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 105 (2 serious)
Citation history
Health deficiencies cited at Rochester Residence And Care Center during CMS and state inspections, most recent first.
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.
The facility did not follow its menu and served unappetizing, improperly prepared meals, such as plain noodles with undressed salad and ground beef with broth, instead of the scheduled entrees. Staff and the RD confirmed that the food provided was not palatable or attractive, and did not meet acceptable standards.
The facility did not provide food according to resident preferences and prescribed diets on two units, as staff and residents reported frequent delivery of incorrect meals and an inability to contact the Dietary Department to request corrections or alternative items. Communication barriers, including an unanswered phone and lack of voicemail, led to delays and unmet resident needs, as confirmed by staff and the registered dietitian.
A resident experienced significant weight loss over several months, with clinical records showing no documentation or interventions to address the issue, despite facility policy requiring monitoring and response to such changes.
A resident with multiple diagnoses was found to have a lice infestation, and treatment was initiated following consultation with a Nurse Practitioner. However, there was no documentation that the resident's emergency contact or family was notified of the condition or the new treatment, as required by facility policy. The DON confirmed the lack of notification documentation.
A resident with diabetes and an insulin pump was admitted without proper documentation or care planning for the device. Nursing staff, including agency and new hires, had not received training on insulin pumps, leading to an LPN incorrectly transcribing and administering insulin. This resulted in the resident experiencing hypoglycemia and requiring hospital transfer due to an accidental insulin overdose. The DON and NHA confirmed that staff lacked the necessary competencies and training for insulin pump care.
A resident with diabetes and other chronic conditions was admitted with orders for insulin via pump, but the nursing admission evaluation failed to document the pump and the care plan did not address its management. An LPN incorrectly transcribed the hospital discharge order, leading to the administration of the wrong type and route of insulin, resulting in an overdose and hypoglycemia that required emergency department treatment.
A resident with diabetes and moderate cognitive impairment was given 90 units of Humulin insulin subcutaneously in error, instead of having the insulin administered via an insulin pump as ordered. The LPN misread the physician's order, leading to an accidental insulin overdose and hypoglycemia, requiring emergency room care. The facility failed to ensure medications were administered as ordered and did not follow the six rights of medication administration.
The facility did not maintain a homelike environment on two nursing floors, as evidenced by reports of fecal matter on bathroom walls, a broken faucet in the spa area, and observations of chipped paint and stains. The Director of Plant Operations confirmed these issues and the facility's failure to meet standards for a comfortable and sanitary environment.
A resident with diabetes who used an insulin pump did not have a care plan that addressed the specific needs and interventions related to the device. The omission led to a nurse administering insulin incorrectly, resulting in hypoglycemia and hospital transfer. Facility leadership confirmed the lack of an individualized care plan for the insulin pump.
Two residents eloped due to inadequate supervision and failure to identify elopement risks. One resident with Alzheimer's was found in a stairwell despite being a known elopement risk, while another resident with dementia fell down stairs in a wheelchair after expressing a desire to leave. The facility did not update care plans or address malfunctioning door mechanisms, contributing to these incidents.
The facility failed to maintain sanitary conditions in the main kitchen and a unit pantry, leading to potential cross-contamination and food-borne illness. Observations revealed dust and grime on kitchen equipment and improper storage of items in the pantry freezer. These deficiencies were confirmed by the Food Services Director and the Nursing Home Administrator.
The facility failed to implement COVID-19 monitoring and testing according to guidelines, did not follow enhanced barrier precautions for a resident with a Foley catheter, and an LPN did not perform hand hygiene during a medication pass, risking cross-contamination.
The facility failed to respond timely to call bells for three residents, resulting in significant delays. A resident with heart failure and diabetes waited 18 minutes, another with congestive heart failure waited an hour, and a third with atrial fibrillation waited 50 minutes for assistance. These delays were confirmed by staff, indicating a breach in the facility's policy on call light response.
The facility did not respond to resident concerns raised during council meetings over six months, violating its grievance policy. Issues included delayed call bell responses, late meal trays, and inconsistent snack cart delivery. Residents reported ongoing dissatisfaction and lack of feedback, with the Nursing Home Administrator confirming the facility's failure to address these concerns.
The facility failed to provide a comprehensive activities program that met the residents' interests and supported their well-being. The activity calendar included Bible study and manicures, but observations showed discrepancies, such as residents watching a movie instead of participating in Bible study. Residents expressed dissatisfaction, citing unmet requests for activities like going outside and attending events. Only four residents received manicures, and the Nursing Home Administrator confirmed the deficiency.
The facility failed to provide privacy for catheter collection bags for four residents and did not develop an individualized care plan for catheter use for one resident. Observations showed visible catheter bags without privacy covers, despite facility policies and physician orders requiring them. Staff confirmed these deficiencies, highlighting a lack of adherence to established care protocols.
The facility failed to timely address significant weight loss for a resident, develop or update nutrition care plans for two residents, and assess the nutritional status of four residents. The facility did not adhere to its policy requiring comprehensive nutritional assessments and care plan updates, leading to a lack of documentation and monitoring of residents' nutritional status.
The facility failed to provide appropriate respiratory care for four residents, as oxygen tubing and nebulizer equipment were not labeled or stored properly. Observations revealed unlabeled and improperly stored equipment, and staff interviews confirmed these deficiencies. The Director of Nursing acknowledged the failure to adhere to respiratory care policies, affecting residents with conditions like COPD and anemia.
The facility failed to provide sufficient nursing staff, resulting in a resident missing dialysis and another resident falling down emergency steps. On multiple days, staffing levels were inadequate, with only two aides available for 45 residents, leading to missed care and supervision. Staff interviews confirmed the inability to meet residents' needs due to insufficient staffing.
The facility failed to properly store and secure medications and biologicals in three medication carts and one treatment cart, as well as in a medication room. Observations revealed unsecured carts and rooms, with medications lacking proper labeling and dating. Staff confirmed these deficiencies, indicating non-compliance with storage policies.
A resident with high blood pressure, depression, and non-Alzheimer's dementia did not receive IV fluids as ordered on two occasions, and the facility failed to notify the physician of these missed and delayed treatments. Additionally, required lab work was not obtained, and the physician was unaware of these deficiencies due to a lack of communication from the facility.
A resident with Alzheimer's and dementia was found with Styrofoam in her mouth, indicating possible neglect. The facility failed to report this incident to the state field office within the required 24-hour timeframe, as confirmed by the Nursing Home Administrator.
A facility failed to investigate an incident where a resident with Alzheimer's, dementia, and PICA ingested a Styrofoam coin. The resident was found with pieces in her mouth and was given pudding to swallow them without choking. The incident was not documented, violating facility policies on incident reporting and investigation.
A resident with a history of anemia, End Stage Renal Disease, and high blood pressure was observed with an active nosebleed and high blood pressure after missing a dialysis session. The facility failed to document the condition or notify the physician, violating their policy on Notification of Changes.
A resident with non-Alzheimer's dementia and other conditions did not receive appropriate treatment to prevent further decrease in range of motion. The resident's care plan included a right resting hand splint and participation in a restorative nursing program, but the splint was not applied as ordered, and the facility lacked a restorative program. Staff interviews confirmed these deficiencies.
A resident with high blood pressure, depression, and non-Alzheimer's dementia did not receive IV fluids as ordered due to a delay in midline placement. Despite physician orders for fluid administration to address hypernatremia and acute kidney injury, the facility failed to administer the fluids timely, as confirmed by medication records and staff interviews.
A resident with End Stage Renal Disease missed a scheduled dialysis session due to not being ready on time, resulting in missed transportation. Facility staff confirmed the incident, and the resident could not attend dialysis until the next scheduled session. The DON acknowledged the failure to provide care consistent with professional standards.
A resident with dementia and PICA ingested a Styrofoam coin, but the facility failed to document timely physician notification and interventions. The incident was not included in the facility's incident report list, indicating a lapse in following dementia care and incident policies.
A resident with Alzheimer's, dementia, and anxiety experienced potential adverse reactions from psychotropic medications. The facility did not act on pharmacy recommendations to address medication-related irregularities, including concerns about falls and low blood pressure. The Nursing Home Administrator confirmed the failure to obtain a physician's response to these issues.
A resident with high blood pressure, depression, and non-Alzheimer's dementia did not receive ordered lab tests on two occasions. The facility failed to conduct a CMP and CBC as ordered by the physician on specified dates. Despite new orders and follow-up, the clinical record showed no evidence of the lab work being completed. Interviews confirmed the oversight, highlighting a deficiency in providing timely laboratory services.
The facility failed to coordinate hospice services for two residents, leading to deficiencies in end-of-life care. One resident's clinical record lacked a hospice agreement and communication, while another resident did not receive recommended medication changes. Staff interviews confirmed these coordination failures.
The facility's QAPI committee failed to address quality deficiencies effectively, leading to two elopement incidents. The first incident involved a resident found in the emergency stairwell, and despite a QAPI meeting, a second resident later eloped and fell down the emergency exit steps. The facility's policy on elopements was not effectively implemented.
A resident with schizophrenia, dementia, and high blood pressure was observed self-administering medications without a documented care plan or interdisciplinary assessment. The facility's policy requires such an assessment to ensure safety, but it was not completed, as confirmed by the Interim DON.
The facility failed to provide proper catheter care and privacy for residents with indwelling catheters. A resident's care plan lacked catheter size specifications, and two residents had visible catheter collection bags without privacy covers. The Interim DON confirmed these deficiencies.
A facility failed to provide sufficient nursing staff, resulting in delayed medication administration for a resident with multiple health conditions. The resident was found in a concerning state, and the only LPN on duty was unable to administer medications on time to 43 residents. The President of Operations was unaware of the staffing issue, confirming the deficiency.
Two residents in an LTC facility experienced significant medication errors. One resident received medications intended for their roommate, requiring IV treatment and monitoring. Another resident was given short-acting insulin instead of long-acting insulin, leading to an emergency room visit. The errors were due to failure in verifying the correct resident and medication.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling Foley catheters. Despite the facility's policy requiring EBP, care plans for two residents lacked documentation, and none of the residents had appropriate signage on their doors. These deficiencies were confirmed through staff interviews and observations.
Rochester Residence and Care Center failed to maintain a clean and homelike environment in five of six nursing units. Observations included vents covered in a dark grey substance, cobwebs, and water-stained ceiling tiles. Maintenance staff confirmed these issues, indicating a lapse in housekeeping and maintenance services.
The facility failed to implement an effective QAPI program for the call bell system, leading to inadequate use of pagers and reliance on kiosks for alerts. Staff interviews revealed confusion and lack of training on the system, with the Nursing Home Administrator acknowledging the issue but not addressing it in QAPI meetings.
The facility failed to ensure the call bell system was fully operational across six units, as staff were not using pagers as required by an exemption. Instead, the system relied on kiosks in hallways and at nurses' stations. Interviews with staff revealed a lack of awareness and use of pagers, and the Nursing Home Administrator confirmed the facility was not using pagers, leading to inadequate notification of resident needs.
The facility failed to maintain a clean and functional environment in the laundry and main storage areas. Observations revealed water puddles and leaks in both areas, with uncovered resident supplies and equipment stored amidst the unsanitary conditions. Maintenance staff confirmed the issues, citing roof leaks and water supply pipe drips as the sources.
The facility failed to report new COVID-19 cases in accordance with national standards. Despite an outbreak beginning in late December, the facility's COVID line listing was not updated to include residents testing positive in late January. An RN confirmed new cases on multiple floors, and the Regional VP admitted to not realizing the need for continuous reporting.
The facility did not meet state-required nurse aide staffing levels during daylight and evening shifts over a 21-day period. On multiple occasions, the number of nurse aides was below the required minimum for the resident census, as confirmed by staffing schedules and census data. The Nursing Home Administrator acknowledged the staffing shortfall.
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.
Failure to Serve Palatable and Menu-Compliant Meals
Penalty
Summary
The facility failed to follow its established menu and did not provide palatable, attractive, or appropriately prepared food during several meals. On specific dates, residents were served meals that did not match the posted menu, such as being given plain buttered noodles and salad without dressing instead of the scheduled chicken fettuccini alfredo, and ground beef with broth instead of beef chili with beans. Staff interviews confirmed that unappetizing and improperly prepared food was served, including scrambled eggs with chicken soup poured over them, which was described as unappealing. The Registered Dietitian verified that the food items served were not palatable and did not meet acceptable standards, and acknowledged that the facility failed to adhere to the planned menus and provide food that was attractive and acceptable to residents.
Failure to Provide Food According to Resident Preferences and Diet Orders Due to Dietary Communication Barriers
Penalty
Summary
The facility failed to provide food products that accommodated resident preferences and prescribed diets for residents on two nursing units, The Gardens and Scenic Heights. During a lunch observation, a nurse aide identified that a resident who was ordered a regular diet received minced and pureed food instead. This issue was reported to the unit clerk, who attempted to contact the Dietary Department but was unable to reach anyone or leave a message, as the phone system did not allow for messages and was frequently unanswered. Staff interviews confirmed that this communication barrier with the Dietary Department was a recurring problem, often resulting in significant delays in correcting meal errors. Residents reported consistently receiving incorrect or undesired food items, with one resident stating that she was regularly given food she would not eat, and another noting that requested items, such as a salad, were repeatedly not provided. Staff, including an LPN, corroborated the difficulty in reaching the Dietary Department to address these issues. The registered dietitian confirmed that the facility failed to provide the correct diet to the affected resident and was unable to honor food preferences for both nursing units due to the inability to take or respond to phone calls for food requests.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to properly monitor and address significant weight loss for one resident. According to the facility's weight monitoring policy, weights are to be recorded monthly and significant changes in weight are defined as a 5% loss in one month, 7.5% in three months, or 10% in six months. Clinical records showed that the resident experienced a 7.6% weight loss in one month, 10.5% in three months, and 11.5% in six months. Despite these significant changes, there was no documentation or evidence of interventions in response to the resident's weight loss during May. The registered dietitian confirmed that the facility did not address the resident's significant weight loss as required.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition or care for one of three residents reviewed. Specifically, a resident with diagnoses including high blood pressure, sepsis, and muscle weakness was found to have live lice and a significant amount of nits present. The resident was reportedly unaware of the lice infestation. Following this discovery, the RN Supervisor consulted with the Nurse Practitioner, obtained and implemented orders for lice treatment, and initiated interim measures until the prescribed shampoo arrived. Despite these actions, a review of the clinical record did not show documentation that the resident's family or emergency contact was notified about the presence of lice or the initiation of new treatment. The facility's policy requires prompt notification of the resident's representative in such situations, regardless of the resident's competency. The Director of Nursing confirmed during an interview that there was no documentation of notification to the resident's representative regarding this change in condition and care.
Failure to Ensure Nursing Staff Competency with Insulin Pump Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to care for a resident using an insulin pump, resulting in immediate jeopardy to the resident's health and safety. The Director of Nursing confirmed that there was no policy in place for insulin pumps, and the facility's policy on competent nursing staff was not followed in this case. Clinical record review showed that a resident with multiple diagnoses, including diabetes, was admitted with an insulin pump, but the nursing admission evaluation did not document the presence of the pump, and the care plan did not address its management. Multiple interviews with RNs and LPNs revealed that none of the nursing staff, including agency staff, had received education or training on insulin pumps. Staff members were unfamiliar with the device, its maintenance, and its operation, with some only having personal knowledge from outside the facility. One LPN, who was working her first shift at the facility, transcribed hospital discharge orders incorrectly, entering the wrong insulin type and route of administration due to lack of training and orientation. This error led to the administration of insulin subcutaneously instead of refilling the pump, resulting in the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. The employee file for the LPN who made the error did not contain evidence of facility orientation or training on the admission process, order transcription, or insulin pump management. The Director of Nursing and Nursing Home Administrator confirmed that staff were not trained on insulin pumps or related processes, and that this lack of training and competency directly resulted in a negative outcome for the resident.
Removal Plan
- Audit residents to identify specialty equipment. If specialty equipment is identified, obtain physician orders. Update care plans to include specialty equipment if applicable.
- Audit admission assessments for residents for special equipment specifically insulin pumps and/or continuous glucose monitors.
- Audit physician orders from discharge paperwork for residents for accuracy.
- Conduct pre-admission resident screening to identify any special equipment. Communicate special equipment needs to the nursing team prior to resident admission. Educate Admissions Director on this process.
- Educate licensed nursing staff (including agency) on conducting pre-admission resident screening to identify any special equipment and communicating special equipment needs to the nursing team prior to resident admission.
- Educate licensed nursing staff (including agency) on assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors.
- Educate licensed nursing staff (including agency) on obtaining physician orders for specialty equipment.
- Educate licensed nursing staff (including agency) on accurate order transcription and admission red lining processes.
- Educate licensed nursing staff (including agency) on care plan updates on specialty equipment.
- Educate licensed nursing staff (including agency) on updated processes.
- Update and review facility policy on medication administration to include specialty equipment, obtaining physician orders, and updating care plans.
- Conduct audits of new resident admission assessments to ensure assessments, redlining, and orders are completed and accurate.
- Submit findings of audits through facility Quality Assurance and Performance Improvement program.
Medication Transcription and Administration Error Resulting in Insulin Overdose
Penalty
Summary
A resident with a history of heart failure, diabetes, and hypertension was admitted to the facility with hospital discharge orders specifying the use of Humalog insulin via an insulin pump, with a maximum daily dose of 100 units. The nursing admission evaluation failed to document the presence of the insulin pump, and the resident's care plan did not address the management of the device. The admitting nurse transcribed the hospital discharge order incorrectly, recording Humulin R to be administered subcutaneously instead of the prescribed Humalog via insulin pump. This transcription error was not clarified with the physician, and the order was not written clearly by the admitting nurse. As a result of these documentation and transcription errors, the resident was administered 90 units of subcutaneous Humulin R, rather than the intended insulin via pump. This led to an insulin overdose and hypoglycemia, requiring the resident to be sent to the emergency department for monitoring and treatment. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the errors in the admission evaluation, order transcription, and medication administration, which resulted in actual harm to the resident.
Significant Medication Error: Insulin Overdose Due to Misinterpretation of Physician Order
Penalty
Summary
A significant medication error occurred when a resident with a history of heart failure, diabetes, and hypertension, who was moderately cognitively impaired, was administered insulin incorrectly. The resident was admitted with orders for insulin to be administered via an insulin pump, with a maximum daily dose specified. However, the nursing admission evaluation did not document the presence of the insulin pump, and the physician's order for insulin was transcribed by an LPN. Subsequently, another LPN misinterpreted the order and administered 90 units of Humulin insulin subcutaneously in a single dose, rather than using the insulin pump as intended. This error was discovered after the resident became groggy, prompting further investigation and transfer to the emergency room, where the resident was diagnosed with hypoglycemia and accidental insulin overdose. Staff interviews and record reviews confirmed that the medication was not administered as ordered by the physician, resulting in actual harm to the resident. The facility failed to ensure adherence to the six rights of medication administration and did not follow its own policy requiring medications to be given as ordered and in accordance with professional standards.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment on two nursing floors, as evidenced by multiple documented concerns and direct observations. Facility policy requires housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment. However, a resident representative reported fecal matter on the bathroom walls, and another reported a broken faucet in the spa area. During observations, surveyors found chipped paint and dark brown stains on the bathroom walls behind the toilet and sink, and a crooked, improperly mounted faucet in the third-floor spa area. The Director of Plant Operations confirmed these findings and acknowledged the facility's failure to create a homelike environment.
Failure to Develop Individualized Care Plan for Insulin Pump Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident who was using an insulin pump for diabetes management. Although the resident's care plan included general interventions for diabetes, such as education on hypo/hyperglycemia and regular blood glucose monitoring, it did not address the specific needs and interventions related to the continuous use of an insulin pump. The care plan omitted critical information about the insulin pump, including its presence and the continuous infusion of insulin, despite this being part of the resident's prescribed treatment. As a result of this omission, a nurse administered 90 units of Humulin insulin subcutaneously instead of using it to refill the insulin pump, leading to the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. Interviews with facility leadership confirmed that there was no care plan in place for the insulin pump, and the facility did not provide individualized interventions to address the resident's specific care needs related to the device.
Failure to Supervise and Identify Elopement Risks
Penalty
Summary
The facility failed to provide adequate supervision and identify residents at risk for elopement, resulting in two residents eloping. Resident R79, who was diagnosed with Alzheimer's, dementia, and macular degeneration, was identified as a high elopement risk. Despite this, the care plan did not include supervision as an intervention. On one occasion, Resident R79 was found in a stairwell after an alarm sounded, indicating a failure in supervision during a shift change. The resident's wander guard was functioning, but the door's egress and magnetic locks were not working properly, contributing to the elopement. Resident R289, diagnosed with heart failure, UTI, non-Alzheimer's dementia, depression, and COPD, was not initially identified as an elopement risk. However, the resident exhibited exit-seeking behavior, frequently expressing a desire to go home. Despite these behaviors, the resident was not provided with a wander guard. During a meal service, Resident R289 managed to open a door with a fire safety mechanism and fell down the stairs in a wheelchair, resulting in a transfer to a trauma center. The facility's failure to update care plans and provide adequate supervision during critical times, such as shift changes and meal services, contributed to these incidents. Staff did not report exit-seeking behaviors in a timely manner, and the facility did not address the malfunctioning door mechanisms promptly, leading to the elopements and subsequent injuries.
Removal Plan
- Resident R79 was returned safely to her room by staff and assessed by RN. No injuries observed and no pain voiced by resident. Elopement risk evaluation updated, and care plan updated to include resident preferences and any triggers for exit seeking behavior. Care plan also updated to include remaining safe on my unit and free of elopements through next review.
- Root cause analysis identified as staff did not report exit seeking behavior timely and facility failed to provide appropriate supervision.
- All residents will have updated elopement risk evaluations completed by DON or designee.
- Care plan interventions for residents identified for elopement risk will be implemented by ensuring staff are provided with person centered interventions. This will be completed by DON or designee.
- Care plan goals for residents who are identified for elopement risk updated to include remaining safe on the unit through staff supervision and free of elopements through next review. This will be completed by DON or designee.
- Whole house education on elopement risks and assessments, supervision, and care plans of residents. This education includes agency staff and staff will be educated prior to their next scheduled shift. This will be completed by NHA or designee.
- Review and update the elopement policy as needed.
- Audits of new exit seeking behaviors will be conducted by DON or designee to ensure evaluations and care plans are up to date. Findings of audits will include updated elopement evaluations and care plan goals/interventions. Ongoing results will be submitted to QA.
Sanitation Deficiencies in Kitchen and Pantry
Penalty
Summary
The facility failed to maintain kitchen equipment and a unit pantry in a sanitary condition, which could lead to cross-contamination and food-borne illness. During a tour of the main kitchen's walk-in cooler, it was observed that the cold air condenser fan covers and the ceiling in front of these fans had accumulated dust, grime, and debris. This observation was confirmed by the Food Services Director (FSD) Employee E16, who acknowledged the unsanitary condition of the kitchen equipment. Additionally, an inspection of the 3rd floor unit pantry freezer revealed the presence of non-food items such as ice packs and silicon ice trays, as well as multiple opened, half-consumed, unlabeled, and undated frozen bottled beverages and ice cream novelties. These findings were also confirmed by FSD Employee E16, indicating a failure to maintain the pantry freezer in a sanitary condition. The Nursing Home Administrator later confirmed these deficiencies, which were in violation of state regulations regarding the responsibility of the licensee and management.
Inadequate COVID-19 Protocols and Infection Control Measures
Penalty
Summary
The facility failed to fully implement COVID-19 monitoring, tracking, and testing in accordance with state and federal guidance during an outbreak. A Registered Nurse tested positive for COVID-19, and the facility conducted testing on residents the same day, which was not in line with CDC guidance that requires testing exposures immediately but not within 24 hours, followed by additional tests at 48-hour intervals. The facility also did not perform contact tracing for the positive staff member and failed to monitor residents daily for new signs and symptoms of respiratory illness. Additionally, the facility did not adhere to enhanced barrier precautions for a resident with a Foley catheter. The resident's room lacked signage indicating the need for enhanced barrier precautions, which is required for residents with indwelling medical devices to prevent the transmission of multidrug-resistant organisms. This oversight was confirmed by a Licensed Practical Nurse during an observation. Furthermore, during a medication pass, a Licensed Practical Nurse failed to perform hand hygiene after coughing into her hands and before attending to another resident. This action posed a risk of cross-contamination between residents. The facility's failure to implement proper infection control measures was confirmed by interviews with the Nursing Home Administrator and Director of Nursing.
Failure to Respond Timely to Call Bells
Penalty
Summary
The facility failed to accommodate the call bell needs of three residents, resulting in delayed responses to their requests for assistance. Resident R26, who has a medical history of heart failure, hypotension, and diabetes mellitus, was observed with an active call bell for 18 minutes without a response. Similarly, Resident R56, diagnosed with congestive heart failure and hypertension, had their call bell activated for one hour before receiving attention. These delays were confirmed by Registered Nurse Employee E25, who acknowledged that the response times exceeded the facility's policy for timely call bell responses. Resident R37, with diagnoses including atrial fibrillation, heart failure, and hyperlipidemia, reported that she had been using her call bell since breakfast without receiving assistance. During an observation, it was noted that her call bell had been on for fifty minutes. Nurse Aid Employee E27 confirmed the duration and mentioned that the resident had been informed about her shower schedule earlier in the shift. These incidents indicate a failure to meet the facility's policy on call light accessibility and timely response, as well as a failure to accommodate the residents' needs and preferences as required by resident rights and care policies.
Facility Fails to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and respond to resident concerns raised during resident council meetings over a period of six months. The facility's policy on Resident and Family Concerns/Grievances, dated January 7, 2025, outlines the responsibilities of the Grievance Official, including overseeing the grievance process, tracking grievances to their conclusion, and issuing written grievance decisions to residents. However, the facility did not adhere to this policy, as evidenced by the lack of response to concerns documented in resident council notes from June 2024 to February 2025. These concerns included issues with call bells not being answered timely, meal trays and snack carts being delivered late or inconsistently, and the lack of activities for residents. During a resident group meeting in March 2025, residents expressed ongoing dissatisfaction with the facility's handling of their concerns, noting that they did not receive feedback or resolutions to the issues raised. Residents also reported that they were not allowed to gather for resident council meetings during COVID outbreaks, further limiting their ability to voice concerns. The Nursing Home Administrator confirmed the facility's failure to respond to resident concerns over the six-month period, highlighting a significant lapse in addressing resident grievances as per the facility's policy.
Failure to Provide Comprehensive Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of its residents. The activity calendar for March 17th through March 21st, 2025, included activities such as Bible study and manicures. However, observations on March 19th revealed that instead of Bible study, two residents were watching a movie in the activity room. Additionally, during a resident group interview, residents expressed dissatisfaction with the activities program, stating that it did not meet their needs and that they were unable to consistently gather for activities or resident council meetings due to COVID-19 restrictions. They also mentioned that their requests to restart activities from a February resident council meeting had not been met. Residents expressed a desire for activities that included going outside, visiting restaurants and shopping, gathering in groups, going for ice cream, and attending ball games. Despite these requests, the activities calendar did not reflect these interests, and residents reported that they did not participate in activities together. On March 21st, the Activity Director was observed entering a resident's room while manicures were scheduled, and it was confirmed that only four residents received manicures. The Nursing Home Administrator acknowledged the facility's failure to provide a comprehensive activities program for the residents.
Failure to Provide Privacy and Individualized Care Plans for Catheter Use
Penalty
Summary
The facility failed to develop an individualized care plan for the use of a urinary catheter for one resident and did not provide privacy for catheter collection bags for four residents. The facility's policy requires comprehensive, person-centered care plans and privacy for catheter use, including covering drainage bags. However, observations revealed that residents had visible catheter bags without privacy covers, contrary to the facility's policy. Resident R64 did not have a care plan addressing foley catheter use, and their catheter bag was not covered. Similarly, Residents R32, R34, and R51 were observed with visible catheter bags without privacy covers, despite physician orders and care plans indicating the need for privacy. Interviews with facility staff confirmed these observations, indicating a failure to adhere to established policies and procedures for catheter care and privacy.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to identify and address significant weight loss in a timely manner for one resident, failed to develop or update an individualized nutrition care plan for two residents, and failed to timely assess the nutritional status of four residents. The facility's policy on Nutritional Management requires a comprehensive nutritional assessment by a dietitian within 72 hours of admission, annually, and upon significant change in condition. However, the facility did not adhere to this policy, as evidenced by the lack of comprehensive nutritional assessments and care plan updates for the affected residents. One resident experienced a 5.4% weight loss in one month, which was not addressed in a timely manner. The resident's clinical record did not show documentation of nutritional status monitoring or updates to the care plan to address the significant weight loss. Another resident's clinical record lacked documentation of nutritional status monitoring and Medical Nutrition Therapy since a specified date, and no nutrition care plan was developed to address the resident's current nutritional status. Additionally, two other residents did not have comprehensive nutritional assessments completed for their annual MDS assessments, and their clinical records lacked documentation of nutritional status monitoring. Interviews with facility staff confirmed these deficiencies. A Dietetic Technician Registered admitted to failing to assess and document one resident's nutritional status due to workload issues. The Nursing Home Administrator acknowledged the facility's failure to identify and address significant weight loss, develop or update individualized nutrition care plans, and timely assess the nutritional status of the affected residents.
Inadequate Respiratory Care Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, specifically in the management of oxygen and nebulizer equipment. The facility's policy required that oxygen tubing and nebulizer equipment be changed weekly and stored properly when not in use. However, observations revealed that the oxygen tubing and nebulizer equipment for Residents R15, R36, R80, and R84 were not labeled with dates, and nebulizers were not stored in bags as required. Staff interviews confirmed these deficiencies, indicating a lack of adherence to the facility's respiratory care policies. Resident R15, who had diagnoses including COPD, was observed with unlabeled oxygen tubing and a nebulizer not stored in a bag. Similarly, Resident R36's nebulizer was found unlabeled and not stored properly, and it was unclear who it belonged to, as the resident's nebulizer treatments had been discontinued. Resident R80, who was observed with an active nosebleed, had oxygen tubing that was not dated, and their care plan did not include oxygen administration or equipment management. Resident R84, diagnosed with COPD and other respiratory conditions, was found with her nasal cannula on the floor while the oxygen concentrator was on, indicating improper use and management of the equipment. The Director of Nursing confirmed the facility's failure to provide appropriate respiratory care for these residents, as required by the facility's policies and state regulations. The deficiencies were identified through observations, staff interviews, and clinical record reviews, highlighting a systemic issue in the management of respiratory care equipment and adherence to established protocols.
Insufficient Staffing Leads to Missed Dialysis and Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on three specific days. On these days, the facility did not have enough staff to ensure the highest practicable physical, mental, and psychosocial well-being of the residents. The facility's policy requires sufficient staff with appropriate competencies to assure resident safety, but this was not adhered to, leading to deficiencies in care. One incident involved a resident with anemia, end-stage renal disease, and high blood pressure who missed a scheduled dialysis appointment because there were only two aides available to start the shift. The nurse aide, who was new and working with an agency, prioritized passing breakfast trays over getting the resident ready for transportation to dialysis. As a result, the resident missed the ride and could not be transported to dialysis that day. Another incident involved a resident with heart failure, UTI, dementia, depression, and COPD who fell down emergency exit steps. The RN Supervisor was also responsible for passing medications and was unable to monitor the resident adequately. The resident expressed a desire to go home and was not supervised due to insufficient staff, leading to the fall. The facility's staffing levels were inadequate to manage the needs of residents, particularly those with cognitive impairments, as confirmed by staff interviews and observations.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications and biologicals properly and securely, as evidenced by several observations and staff confirmations. Three out of six medication carts, specifically the Grandview, Riverside, and Rosewood carts, were found to contain medications and biologicals that were not stored according to professional principles. For instance, the Riverside medication cart had an opened vial of Lantus insulin without a date, and the Grandview cart contained multiple items such as a foley catheter insertion tray, liquid protein, and Haldol without dates, as well as a medication pill planner with unidentified medications. Additionally, the Rosewood cart contained lidocaine patches and non-medical items like goldfish crackers. Furthermore, the facility failed to secure treatment medication in one of four treatment carts and did not secure one of two medication rooms. Observations revealed that the treatment cart on the Riverview hallway was left unsecured and unattended, accessible to passersby. Similarly, the fourth-floor medication room was found open and without a secure lock, making it accessible to unauthorized individuals. Staff interviews confirmed these observations, indicating a failure to adhere to the facility's policy on medication storage, which requires medications and biologicals to be stored safely, securely, and properly.
Failure to Notify Physician of Missed and Delayed Treatments
Penalty
Summary
The facility failed to notify the physician of a change in treatment in a timely manner for a resident with diagnoses of high blood pressure, depression, and non-Alzheimer's dementia. The resident was ordered to receive intravenous (IV) fluids for hypernatremia, but the facility did not administer the fluids as ordered on two occasions. On the first occasion, the resident did not receive the prescribed one liter of 5-0.45% Dextrose-Sodium Chloride solution due to a midline not being placed, and there was no evidence that the physician was notified of this failure. On the second occasion, there was a delay in administering two liters of Dextrose 5% in Water (D5W) for acute kidney injury and hypernatremia, and again, the physician was not informed of the delay. Additionally, the facility failed to obtain lab work as ordered for the resident, which included a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC) for acute kidney injury, hypernatremia, and anemia. The Nursing Home Administrator confirmed the facility's failure to notify the physician of the missed and delayed treatments, as well as the failure to obtain the required lab work. The Medical Doctor involved was under the assumption that all treatments and lab work had been completed as ordered, highlighting the lack of communication from the facility.
Failure to Report Possible Neglect Incident
Penalty
Summary
The facility failed to report an allegation of possible neglect within the required 24-hour timeframe to the local state field office for one resident. The facility's policy on Abuse, Neglect, and Exploitation mandates immediate investigation and reporting of any allegations of abuse or neglect. However, the incident involving the resident was not reported as required. The resident, who has Alzheimer's Disease, dementia, and anxiety, was found in the sunroom with pieces of a gold glitter Styrofoam coin in her mouth. Despite attempts by the nurse to remove the pieces, the resident did not allow it, and pudding was given to help her swallow without choking. The facility's documentation from the incident date to the survey date did not include any report of this incident to the local state field office. During an interview, the Nursing Home Administrator confirmed the failure to report the incident within the required timeframe. This deficiency was identified for one of seven residents reviewed, highlighting a lapse in adhering to the facility's policies and state regulations regarding timely reporting of potential neglect.
Failure to Investigate Incident of Foreign Object Ingestion
Penalty
Summary
The facility failed to conduct a thorough investigation of an incident involving a resident, identified as Resident R30, who ingested a foreign object. The incident occurred when Resident R30, who has a history of Alzheimer's Disease, dementia, and PICA, was found in the sunroom with pieces of a gold glitter Styrofoam coin in her mouth. Despite the nurse's attempt to remove the pieces, the resident did not allow it, and was instead given pudding to swallow the pieces without choking. The incident was not documented in the facility's list of incidents, indicating a failure to follow the facility's policy on reporting and investigating incidents. The facility's policies on Abuse Neglect, and Exploitation, as well as Incidents and Accidents, require immediate investigation and documentation of incidents involving residents. However, the facility did not adhere to these policies, as evidenced by the lack of a thorough investigation and documentation of the incident involving Resident R30. The Nursing Home Administrator confirmed this failure during an interview, acknowledging that the facility did not conduct a thorough investigation to rule out possible neglect in this case.
Failure to Document and Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to document an assessment and notify the physician of a change in condition for Resident R80. The resident, who has a history of anemia, End Stage Renal Disease, and high blood pressure, was observed with an active nosebleed while in a wheelchair in the hallway. The resident was also noted to have high blood pressure and had missed a scheduled dialysis session. Despite these observations, the progress notes for the day did not include documentation of the nosebleed, an assessment of the condition, a blood pressure reading, or notification to the physician about the missed dialysis and symptoms. The facility's policy on Notification of Changes requires prompt communication with the resident, their physician, and their representative when there is a change requiring notification. However, this protocol was not followed in the case of Resident R80. The Director of Nursing confirmed the failure to document the assessment and notify the physician, which is a violation of the facility's responsibilities under the relevant state codes.
Failure to Provide ROM Treatment for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for Resident R32. The resident, who was admitted with diagnoses including non-Alzheimer's dementia, anxiety, and high blood pressure, had a physician's order for a right resting hand splint to be applied during morning care and removed during evening care, with skin checks to be completed upon application and removal. However, during an observation, the resident was found with a blue washcloth rolled in the right hand instead of the prescribed splint, indicating non-compliance with the physician's order. Interviews with facility staff, including an occupational therapist and a registered nurse, revealed that the facility did not have a restorative program in place, which was part of the resident's care plan to improve range of motion. The care plan was not reflective of the current treatment being provided, and the Director of Nursing confirmed the facility's failure to provide the necessary treatment and services to prevent further decrease in range of motion for the resident.
Failure to Administer IV Fluids Timely and as Ordered
Penalty
Summary
The facility failed to ensure the safe and timely administration of IV fluids for a resident, identified as R290, as per physician orders. Resident R290, who was admitted with diagnoses including high blood pressure, depression, and non-Alzheimer's dementia, had a physician order dated 3/14/25 for the administration of one liter of 5-0.45% Dextrose-Sodium Chloride at 50 ml/hr for hypernatremia. However, the resident did not receive the ordered IV fluids because a midline was not placed, as documented in the medication administration record. Further, on 3/17/25, a physician order was issued to administer two liters of Dextrose 5% in Water at 100 ml/hr for acute kidney injury and hypernatremia, starting at 12:00 p.m. The medication administration record for this order was left blank, indicating the fluids were not administered as scheduled. A progress note later that day confirmed that a midline was inserted at 9:32 p.m., and the D5W infusion began at that time, indicating a delay in treatment. Interviews with facility staff, including the Nursing Home Administrator and a Medical Doctor, revealed a lack of awareness and communication regarding the administration of the IV fluids, contributing to the deficiency.
Failure to Ensure Timely Dialysis for Resident
Penalty
Summary
The facility failed to provide hemodialysis care and services consistent with professional standards of practice for Resident R80. The resident, who has diagnoses of anemia, End Stage Renal Disease, and high blood pressure, was scheduled for dialysis every Monday, Wednesday, and Friday as per the physician's order. On the day of observation, Resident R80 missed his scheduled dialysis appointment because he was not up on time, resulting in him missing his transportation to the dialysis center. Interviews with facility staff, including a Nurse Aide and a Registered Nurse, confirmed that the resident missed his ride and that alternative transportation could not be arranged for that day. Consequently, Resident R80 was unable to attend his dialysis session and would not receive treatment until the next scheduled session. The Director of Nursing acknowledged the facility's failure to provide the necessary care and services for hemodialysis as required by professional standards.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to ensure that a resident with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident R30, who was diagnosed with Alzheimer's Disease, dementia, and an eating disorder, exhibited behavior symptoms such as wandering and placing non-food items in their mouth due to cognitive impairment and PICA. On a specific date, the resident was found in the sunroom having bitten into a gold glitter Styrofoam coin, with pieces still in their mouth. The nurse attempted to manage the situation by giving the resident pudding to help them swallow without choking, but there was a failure to document timely notification of the physician, obtain orders, and record immediate interventions. The facility's incident report list did not include the incident of Resident R30 ingesting a foreign object, indicating a lapse in the documentation process. The facility's policies on dementia care and incidents and accidents require staff to report, investigate, and document such occurrences, but these procedures were not followed in this case. The Nursing Home Administrator confirmed the facility's failure to provide the necessary care and services for the resident, as required by the relevant state codes.
Failure to Address Medication Irregularities for a Resident
Penalty
Summary
The facility failed to ensure that irregularities identified in the medication regimen reviews (MRR) by the pharmacy were addressed for a resident. The resident, who was admitted with diagnoses of Alzheimer's Disease, dementia, and anxiety, was noted to have a potential for adverse reactions from ongoing use of psychotropic medications. The resident's care plan included attempts for gradual dose reduction unless contraindicated, monitoring for side effects, and consulting psychiatric services as needed. However, the pharmacy's recommendations from October 2024, which highlighted concerns about the resident's medications potentially contributing to recent falls and low diastolic blood pressure, were not acted upon. The pharmacy's MRR dated January 7, 2025, indicated that medications such as Seroquel, Ativan, and Trazadone might have aggravated the resident's condition, and recommended considering lab orders and psychiatric re-evaluation for possible gradual dose reduction. Despite these recommendations, the facility did not obtain a physician's response to address the identified irregularities. This inaction was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to ensure the attending physician reviewed and documented actions regarding the pharmacist's identified irregularities.
Failure to Obtain Ordered Laboratory Services for a Resident
Penalty
Summary
The facility failed to obtain laboratory services as ordered for Resident R290, who was admitted with diagnoses including high blood pressure, depression, and non-Alzheimer's dementia. The physician had ordered a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC) to be conducted on March 17, 2025, due to hypernatremia. However, the clinical record did not show evidence that these lab tests were conducted as ordered. A progress note indicated that labs were obtained on March 14, 2025, but not on the specified date of March 17, 2025. Further review revealed that a follow-up note from a Certified Registered Nurse Practitioner on March 19, 2025, confirmed that the labs were not completed as ordered on March 17, 2025. A new order was placed for the labs to be drawn on March 19, 2025, but again, the clinical record lacked evidence that the lab work was obtained. Interviews with the Nursing Home Administrator and a Medical Doctor confirmed the failure to obtain the lab work as ordered. This deficiency is a violation of the facility's responsibility to provide timely laboratory services as per physician orders.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services for two residents, leading to deficiencies in end-of-life care. For Resident R15, the clinical record did not include a written agreement with the hospice provider specifying the care and services to be provided. Additionally, there was a lack of maintained communication with the hospice regarding the resident's plan of care, and the hospice binder was not kept up to date. Interviews with staff confirmed the absence of a current hospice binder and a hospice contract for Resident R15. Resident R30, who was diagnosed with Alzheimer's Disease and dementia, was admitted to hospice care. However, the facility failed to implement hospice recommendations to discontinue Seroquel and order Zyprexa to manage the resident's behaviors of PICA. The clinical record did not include an order for Zyprexa, and interviews with staff confirmed that the medication was never ordered, indicating a failure in coordinating hospice services with the facility's care plan. The deficiencies were confirmed through staff interviews and a review of clinical records, highlighting the facility's failure to coordinate hospice services effectively for the residents involved. The lack of proper documentation and communication between the facility and hospice providers contributed to the inadequate end-of-life care for these residents.
Repeated Elopement Incidents Highlight QAPI Deficiency
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address quality deficiencies effectively, as evidenced by two elopement incidents involving residents. The first incident occurred on February 6, 2025, when a resident was found off the unit in the emergency stairwell after an alarm sounded. Despite the QAPI committee meeting on the same day to address the issue, the corrective measures were insufficient. A second incident occurred on March 10, 2025, when another resident eloped and fell down the emergency exit steps. This repeated occurrence indicates that the facility's plans to improve the delivery of care and services did not adequately address the concerns identified during the initial elopement. The facility's policy on elopements and wandering residents, which was last reviewed on January 7, 2025, was not effectively implemented to prevent these incidents.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for one resident, identified as Resident R1. The facility's policy requires an interdisciplinary team to determine which medications a resident may safely self-administer. However, Resident R1, who has diagnoses of schizophrenia, dementia, and high blood pressure, was observed with a medication cup containing seven pills on her bedside table. She indicated that she takes her medications after having her coffee, which was confirmed by a nurse aide and an LPN. Despite this practice, there was no care plan, physician order, or interdisciplinary assessment documented in Resident R1's clinical record to support her self-administration of medications. The Interim Director of Nursing confirmed that Resident R1 did not have the necessary documentation or assessment to self-administer medications safely. This oversight was identified during a review of the resident's clinical record and through interviews with facility staff. The deficiency highlights a lapse in following the facility's policy for medication self-administration, as the required interdisciplinary assessment and documentation were not completed for Resident R1.
Deficiency in Catheter Care and Privacy
Penalty
Summary
The facility failed to ensure proper catheter care and privacy for residents with indwelling catheters, as evidenced by the lack of physician order specifications for catheter size and the absence of privacy bags for catheter collection bags. Resident R4's care plan did not specify the size of the catheter to be used, and the physician's order was incomplete, lacking necessary specifications. Additionally, Resident R4 was observed with a visible catheter collection bag without a privacy cover, which was confirmed by the LPN and the Interim Director of Nursing. Similarly, Resident R5's care plan did not address the use and management of the indwelling urinary catheter, despite the presence of a physician order specifying a 16 French catheter with a 10cc balloon. Resident R5 was also observed with a visible catheter collection bag without a privacy bag. Resident R6's care plan failed to specify the catheter size, although the physician order did include this information. Resident R6 was observed with a visible catheter collection bag without a privacy cover, confirmed by an RN. The Interim Director of Nursing acknowledged the facility's failure to provide necessary catheter specifications and privacy for the collection bags.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, specifically in administering medications within the required time guidelines. This deficiency was observed in the case of a resident who had not received their morning medications on time. The resident, who had been admitted with diagnoses including renal insufficiency, stroke, and hemiplegia, was found in a concerning state with oxygen removed, dried blood in the nostril, pale skin, and labored breathing. A registered nurse confirmed these observations and attempted to address the resident's condition by replacing the oxygen cannula. Further investigation revealed that the licensed practical nurse on duty was the only nurse available to administer medications to 43 residents, which led to the delay in medication administration for the resident in question. The nurse confirmed that the morning medications had not been given within the time guidelines. The President of Operations was unaware of the staffing issue and acknowledged the failure to provide sufficient nursing staff to meet the needs of the residents, as required by the facility's policy and state regulations.
Significant Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. For the first resident, the error occurred when a Registered Nurse (RN) administered medications intended for the resident's roommate. The medications included Metformin, Glipizide, Abilify, Amlodipine, and Gabapentin, which were not prescribed for this resident. The error was self-identified by the RN after the administration. As a result, the resident required intravenous treatment and close monitoring due to the inadvertent administration of incorrect medications. The second resident experienced a medication error when an RN administered short-acting insulin (Lispro) instead of the prescribed long-acting insulin (Lantus). This error was discovered when the RN noticed the pen's color and label after administration. The resident's blood sugar was checked, and due to the error, the resident was sent to the emergency room for monitoring and received intravenous fluids. The emergency room report confirmed the administration of the incorrect insulin type. Interviews and documentation confirmed that the facility did not ensure residents were free from significant medication errors. The errors involved incorrect medication administration due to failure to verify the correct resident and medication, leading to potential health risks for the residents involved. The facility's policies on medication administration and error prevention were not adequately followed, resulting in these significant medication errors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy for three residents, leading to a deficiency in infection prevention and control. Resident R5, who had an indwelling Foley catheter, did not have EBP requirements documented in their care plan, nor was there signage indicating EBP on their door. Similarly, Resident R6, also with a Foley catheter, had EBP requirements in their care plan, but there was no signage on their door. Resident R7's care plan and physician orders failed to include EBP related to their Foley catheter, and there was no signage on their door either. These deficiencies were confirmed through observations and interviews with facility staff, including Registered Nurses and the Interim Director of Nursing. The lack of proper signage and documentation for EBP, as required by the facility's policy, was evident for Residents R5, R6, and R7, all of whom had indwelling Foley catheters. This oversight was acknowledged by the Interim Director of Nursing, indicating a failure to follow the established infection control protocols for these residents.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
Rochester Residence and Care Center was found to be non-compliant with the requirements for maintaining a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During an abbreviated survey conducted in response to two complaints, it was observed that five out of six nursing units, specifically lilac lane, rosewood, riverview, hilltop, and grandview, failed to meet these standards. Observations included ceiling cold air return vents covered in a dark grey fuzzy substance, visible cobwebs, ceiling light covers with a blackish substance, drooping ceiling panels, missing ceiling tile pieces, and water-stained ceiling tiles. The facility's policy on providing a safe and homelike environment, last reviewed on January 7, 2025, was not adhered to, as evidenced by the unsanitary and disordered conditions noted during the facility tour. Maintenance Employee E3 confirmed these observations and acknowledged the failure to maintain a clean environment in the newer part of the building. This deficiency was determined based on both observation and staff interviews, highlighting a significant lapse in housekeeping and maintenance services necessary to ensure a sanitary and comfortable living space for residents.
Plan Of Correction
1. Cold air return vents, ceiling tiles, and ceiling light covers were cleaned/replaced. 2. Education to EVS staff on a safe clean/homelike environment will be conducted by EVS manager or designee. 3. Audits of cold air return vents/tiles/light covers will continue weekly x 3 weeks and monthly x 2 months. 4. Results of audits will be submitted to facility QA process.
Deficiency in Call Bell System Management
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program specifically related to the call bell system pager use. The facility's policy on 'Call Bells: Accessibility and Timely Response' indicates that call bells should directly relay to a staff member or a centralized location to ensure an appropriate response. However, the facility's documentation and staff interviews revealed that the call bell system was not functioning as intended. The system was supposed to alert staff through kiosks and pagers, but the pagers were not being used effectively, and staff were not adequately informed or trained on their use. Interviews with various staff members, including maintenance employees, occupational therapists, registered nurses, and nurse aides, highlighted inconsistencies and confusion regarding the call bell system. Many staff members were unaware of the pager system or confirmed that it was not in use. Some staff mentioned that pagers were available but not functioning correctly, leading to reliance on kiosks in hallways and nursing stations to identify activated call bells. This situation resulted in staff having to physically check kiosks to determine which resident required assistance, which was not in line with the facility's policy or the intended design of the call bell system. The Nursing Home Administrator acknowledged the lack of pager use and expressed a desire to implement them. However, it was confirmed that the call bell pager system had not been included in the facility's QAPI meetings, indicating a failure to address this issue through the QAPI program. This oversight contributed to the deficiency, as the facility did not effectively utilize its QAPI program to focus on outcomes related to the call bell system, impacting the timely response to residents' needs.
Plan Of Correction
1. Call bell pagers are in place for each unit and nursing employee. Nursing staff are to sign out the pagers at the start of their shift and return them when their shift is completed. The pagers work in conjunction with the call bell kiosks on the units. Residents will continue to use the current call system by utilizing the call bell in their room. 2. Facility staff will be educated on the pager system. This will be conducted by the DON or designee. 3. The functionality and response time of the pagers will be tested by the maintenance director/DON or designee daily x 5 days, weekly x 3 weeks, then monthly x 2 months. 4. Resident interviews will be conducted on call bell response time by social services director or designee. 10% of residents will be audited daily x 5 days, weekly x 3 weeks, then monthly x 2 months. 5. Monthly QAPI meetings are in place and the call bell system is placed on a performance improvement plan for monitoring including audits and resident interviews. 6. Results of PIP will be submitted and reviewed through internal QA process.
Deficiency in Call Bell System Due to Lack of Pager Use
Penalty
Summary
The facility failed to ensure that the call bell system was in full working order across six units, namely Lilac Lane, Vineyard, Rosewood, Riverview, Hilltop, and Grandview. The deficiency was identified through a review of facility policy, documents, staff interviews, and observations. The facility had an exemption dated 10/3/19, which required the use of pagers by staff to notify them directly of an activated call bell. However, it was found that staff were not in possession of pagers, and the system relied solely on kiosks placed in hallways and at nurses' stations to indicate when a call bell was activated. Interviews with various staff members, including maintenance employees, occupational therapists, registered nurses, and nurse aides, revealed a lack of awareness and use of the pager system. Maintenance Employee E3 and Occupational Therapist Employee E6 confirmed the presence of kiosks but were unaware of any pager system. Registered Nurse Employee E5 mentioned that pagers were used in the past but were no longer in use, and expressed that pagers would be helpful for responding to call bells. Other staff members, including Nurse Aide Employees E7, E10, and E11, also indicated that the system relied on kiosks and that pagers were not currently in use. The Nursing Home Administrator (NHA) confirmed that the facility was not using pagers and was unaware of the pager requirement in the exemption. The NHA was observed distributing gold ring bells to residents as a backup system, indicating a lack of confidence in the current call bell system. The deficiency highlights the facility's failure to comply with the exemption requirements, resulting in a call bell system that does not adequately notify staff of resident needs.
Plan Of Correction
1. Call bell pagers are in place for each unit and nursing employee. Nursing staff are to sign out the pagers at the start of their shift and return them when their shift is completed. The pagers work in conjunction with the call bell kiosks on the units. Residents will continue to use the current call system by utilizing the call bell in their room. 2. Facility staff will be educated on the pager system. This will be conducted by the DON or designee. 3. The functionality and response time of the pagers will be tested by the maintenance director/DON or designee daily x 5 days, weekly x 3 weeks, then monthly x 2 months. 4. Resident interviews will be conducted on call bell response time by social services director or designee. 10% of residents will be audited daily x 5 days, weekly x 3 weeks, then monthly x 2 months. 5. Monthly QAPI meetings are in place and the call bell system is placed on a performance improvement plan for monitoring including audits and resident interviews. 6. Results of PIP will be submitted and reviewed through internal QA process.
Facility Fails to Maintain Sanitary and Functional Storage Areas
Penalty
Summary
The facility failed to maintain a clean, sanitary, and functional environment in both the laundry room storage area and the large main storage area located on the lower level. During an observation, two large puddles of water were found on the floor of the laundry storage area, with the right corner of the room roped off with caution tape. This area was being used to store resident supplies, including uncovered pillows and boxes of briefs, as well as floor cleaning supplies and trash can liners. Maintenance Employee E3 confirmed the presence of the water, attributing it to a roof leak located under the front parking lot. In the large main storage area, four large buckets were observed collecting water dripping from the ceiling. This area was used to store numerous wheelchairs, bed frames, mattresses, and trash isolation bins. Maintenance Employee E3 confirmed that the drips were coming from the main water supply pipes entering the building. The facility's failure to ensure a clean, sanitary, and functional environment in these areas was acknowledged by the maintenance staff.
Plan Of Correction
1. Maintenance identified the source of the leak as an external leak from the ceiling. Housekeeping storage area leak has been mitigated, and ceiling waterproofing measures have been implemented and area cleaned. 2. Education for EVS and maintenance staff on maintaining a safe/homelike environment will be conducted by EVS manager or designee. 3. Audits of ceiling leaks will be conducted weekly x 3 weeks then monthly x 3 months. 4. Results of audits/education will be submitted to QA for internal monitoring.
Failure to Report Communicable Diseases
Penalty
Summary
The facility failed to maintain a system for reporting communicable diseases, specifically COVID-19, for residents in accordance with accepted national standards. This deficiency was identified through a review of the facility's policy on 'Transmission-Based Isolation Precautions,' which was last reviewed on January 7, 2025. The policy indicates that the facility is responsible for taking appropriate precautions to prevent the transmission of pathogens. However, the facility's COVID line listing showed an outbreak beginning on December 27, 2024, with the last resident testing positive on January 23, 2025. The listing was not updated to include residents who tested positive on January 27 and January 28, 2025. During an observation and interview on January 28, 2025, a Registered Nurse (RN) was seen distributing N95 masks and placing PPE in hallways, indicating the presence of COVID-19 cases on multiple floors. The RN confirmed a resident had tested positive on the 3rd floor that day. Additionally, the Regional Vice President of Operations admitted that the facility failed to report new cases of COVID-19 after the initial two cases were reported on December 27, 2024. The Vice President acknowledged a lack of awareness regarding the need for continuous reporting of additional cases, leading to the facility's failure to report new COVID-19 cases.
Plan Of Correction
1. New cases of reportable diseases (covid) were reported to DOH via ERS system. Line listing for covid and all diseases/infections updated and tracked by facility IP/DON. 2. The NHA will be educated by VP of Operations or designee on reportable diseases to Pa DOH event reporting system. 3. An audit of reportable diseases will be completed weekly x 3 weeks then monthly x 2 months. 4. Results of audits submitted to facility QA process.
Failure to Meet State-Required Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the state-required minimum staffing levels for nurse aides during both daylight and evening shifts over a 21-day period. Specifically, the facility did not provide the required minimum of one nurse aide per 10 residents during the daylight shift on five occasions and one nurse aide per 11 residents during the evening shift on six occasions. The specific dates of non-compliance were identified as 1/13/25, 1/20/25, 1/24/25, 1/25/25, and 1/27/25 for the daylight shift, and 1/7/25, 1/12/25, 1/13/25, 1/24/25, 1/25/25, and 1/27/25 for the evening shift. The deficiency was confirmed through a review of the facility's nurse staffing schedules and census data, which showed that the number of nurse aides on duty was consistently below the required levels. For example, on 1/13/25, the facility needed 73.50 nurse aides for a census of 98 residents but only had 68.49. Similarly, on 1/25/25, the facility needed 75.00 nurse aides for a census of 100 residents but only had 56.65. The Nursing Home Administrator acknowledged the failure to meet the staffing requirements during an interview conducted on 1/28/25.
Plan Of Correction
1. The facility is actively hiring nurse aides for daylight and evening shifts. Shift pick up bonuses and sign on bonuses for new hires are offered. Shift differentials are offered for evening shifts. Job fair is scheduled for 2/19/2025. 2. Education on nurse aide ratios will be provided to the nurse scheduler and DON by NHA or designee. 3. Daily audits of nurse aide ratios will be completed by nurse scheduler. 4. Results of audits will be submitted to internal QA process for monitoring.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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