Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seneca Place during CMS and state inspections, most recent first.
The facility failed to maintain dignity for two residents with urinary catheter bags by leaving the bags uncovered while they were in bed, and failed to provide bodily privacy for a resident during wound care when the door was left open and the privacy curtain was not pulled. Staff confirmed the uncovered catheter bags and the lack of privacy during treatment.
The facility failed to obtain physician orders for blood sugar management parameters for two residents with diabetes, failed to notify the physician after one resident had a hypoglycemic episode, and failed to obtain an order for a condom catheter for another resident. One resident’s insulin order lacked hypoglycemia parameters and a blood sugar of 65 was documented with no physician notification, another resident’s insulin order lacked both hypoglycemia and hyperglycemia parameters, and a resident was observed with a condom catheter bag despite no physician order in the record.
Incomplete dialysis communication and access site monitoring: The facility failed to maintain complete dialysis communication records for three residents with ESRD or dialysis dependence, and failed to document ordered AV fistula checks for two residents. One resident had conflicting AV fistula orders, while another had repeated missing thrill and bruit documentation on the TAR. The DON and NHA confirmed the documentation failures.
Medication Labeling and Storage Deficiencies: Multiple medication carts and a medication room refrigerator contained opened or stored medications without required dates, including inhalers, eye drops, insulin, nebulizer solutions, and oral/topical meds. Staff, including RNs and LPNs, confirmed that several items lacked expiration or opened dates and that some meds were stored improperly with oral medications or outside required storage conditions.
Infection control failures were identified involving a resident refrigerator without the required temp log, a laundry worker who picked a washcloth off the floor and returned it to clean linens, a wound care RN who did not establish a clean field and placed opened supplies on a trash can liner during a dressing change, and a water mgmt program that lacked proof of current Legionella testing beyond 2024.
Failure to Assess Self-Administration of Medications: A resident with HF, HTN, and DM had fluticasone nasal spray and an albuterol inhaler kept at bedside, but the clinical record lacked an assessment or MD order for self-administration. The resident said they kept the meds nearby so they would not have to wait for nursing staff, and the UM confirmed the facility had not determined whether self-administration was safe or clinically appropriate.
A resident with Parkinson’s disease, CKD, Sjogren syndrome, acute Lyme disease, and altered mental status developed a new behavior of kneeling on the floor while wandering the unit. Although staff observed the behavior and said it was known to nursing, the record did not show notification to the resident’s family about this behavioral concern, despite the facility policy requiring prompt notification of the resident, physician, and representative when there is a change in condition.
Failure to assess whether a mattress bolster was a restraint for a resident with dementia, anemia, and HTN. The resident’s care plan included bolsters to bed for fall risk, and staff observed the resident in bed with bilateral raised mattress edges, but the record had no assessments or ongoing evaluations of bolster use. A UM confirmed the facility did not assess the resident’s functional status to determine whether the bolster was a restraint.
A resident with Parkinson’s disease, CKD, Sjogren syndrome, acute Lyme disease, and altered mental status developed wandering and purposeful kneeling behavior in the hallway, but the care plan was not updated to reflect this new behavior. Notes documented pacing, wanting to leave, confusion, and later observations of the resident kneeling and standing back up while wandering, yet the record did not include a care plan for this behavior.
Failure to provide ordered pressure ulcer treatment. A resident with bilateral heel pressure injuries, wound infection, and muscle weakness had care plans and MD orders for daily wound care and heel offloading boots while in bed. Review of the TAR showed multiple missed or undocumented wound care and boot applications for both heels, and the DON confirmed the facility failed to ensure proper treatment was provided.
MRR documentation for a resident with anemia, atrial fibrillation, and HTN was not signed by the physician as required. The consultant pharmacist's monthly MRRs were instead signed by a PA, and the DON confirmed this during interview.
A resident sustained burns to both hands from hot coffee during the evening shift, resulting in redness and blistering, and the on-call physician recommended hospital evaluation and treatment, which the resident refused. The facility’s investigation did not include a summary of findings, witness statements, or staff/resident interviews about how the injury occurred, and the Dietary Manager stated coffee temperatures were not taken before or during tray line service.
A resident admitted with a colostomy and related diagnoses did not have physician orders written on admission for colostomy supplies and care. Although later orders included appliance changes, a specific pouch, and colostomy care every shift, the DON confirmed the orders were not written on admission as required.
A resident with mood disorder, brain injury, and dysphagia burned both hands after spilling hot coffee during the evening shift. Records showed coffee was served at high temperatures, with a documented temperature drop during tray delivery, and the DON stated the resident did not report the spill until later that evening and refused hospital transfer. The NHA confirmed the facility failed to ensure a safe environment resulting in the burn.
The facility did not investigate or document incidents involving two residents—one with toe abrasions from a shower chair incident and another found without a required monitoring device—contrary to its policies. Additionally, two nursing staff members, an LPN and an RN, began employment without completed state criminal background checks, as confirmed by facility staff.
The facility did not identify or investigate incidents involving three residents, including a resident who sustained abrasions during care, another who attempted to leave the facility on multiple occasions, and a third who was found without a required safety device. These incidents were not documented or investigated as required, and facility leadership confirmed the lack of appropriate follow-up.
Care plans were not updated for three residents after significant changes in their health status, including two residents who tested positive for Norovirus and another who received an indwelling urinary catheter. The care plans lacked goals and interventions addressing these new needs, as confirmed by clinical record review and staff interviews.
The facility failed to follow physician orders and treatment protocols for several residents, including not changing or documenting IV dressings, not completing wound care as ordered, not arranging timely follow-up appointments with specialists, and not labeling medicated patches with the date and time of application. Staff confirmed these lapses during interviews and observations.
Three residents with orders for CPAP/BIPAP therapy were found to have their respiratory masks left unbagged on bedside tables, in violation of facility policy requiring proper storage. Despite clear care plans and physician orders, staff did not ensure masks were bagged when not in use, and this was confirmed by both nursing staff and the DON.
The facility failed to maintain consistent communication with the dialysis center for two residents, resulting in numerous days of incomplete or missing records. Additionally, two residents did not have physician orders for dialysis access device care, and care plans were incomplete or lacked necessary details about the access devices. These deficiencies were confirmed by staff interviews and record reviews.
Surveyors found that medications and biologicals were not properly stored or labeled in three medication carts. Issues included insulin pens and vials lacking dates opened or resident identifiers, an open insulin pen without a cap, oral medications repackaged in unapproved containers, and topical medications stored in the wrong cart. These deficiencies were confirmed by nursing staff and the DON.
The facility did not follow infection prevention protocols, including Enhanced Barrier Precautions for two residents with indwelling catheters, failed to implement Contact Precautions for four residents with norovirus, lacked infection surveillance for two months, and an LPN was observed applying a lidocaine patch without gloves.
A resident with multiple chronic conditions sustained skin injuries to the right foot after it was dragged on the carpet while being pushed in a shower chair. Although the incident was documented in the medical record, it was not reported to the State Department of Health as required by facility policy. The Nursing Home Administrator confirmed the omission during an interview.
Two residents with moderate cognitive impairment were able to leave or attempt to leave unsupervised areas due to inadequate supervision and failure to follow elopement prevention protocols, including missing required alarm devices and insufficient monitoring.
A resident with multiple medical conditions had an indwelling urinary catheter ordered without a documented diagnosis to justify its use, contrary to facility policy requiring clinical indications to be reviewed and documented prior to insertion. This lapse was confirmed by an RN during staff interviews.
The facility did not complete required annual performance evaluations for multiple nursing staff, including nurse aides and an LPN, as outlined in facility policy. Personnel records lacked documentation of these evaluations, and the administrator confirmed the omission.
A resident with a documented seafood allergy was served shrimp alfredo, resulting in vomiting and a grievance from the resident's family. The allergy was noted in the clinical record, nutrition assessment, and physician orders, but the dietary manager confirmed the resident did not receive the correct diet.
The facility did not verify that a resident with severe cognitive impairment had the capacity to understand and sign a binding arbitration agreement, and also failed to obtain a required signature for another resident's arbitration agreement, as confirmed by the admissions director and documented in facility records.
The facility did not ensure that all required QAA committee members, including the Infection Preventionist, were present at a quarterly meeting, as shown by attendance records and confirmed by the DON. This failure was not in accordance with facility policy and regulatory requirements.
The facility did not implement its antibiotic stewardship program for one month, as required by policy. Review of infection control records showed no documentation of antibiotic monitoring for that period, and the DON confirmed the lapse.
The facility did not have a qualified infection preventionist onsite to oversee infection prevention and control activities for a period after the previous infection preventionist resigned and before the new one completed required training and certification, as confirmed by the DON and facility records.
Essential emergency equipment audits were not completed for two crash carts, as daily logs showed missing entries and staff confirmed the required checks had not been performed.
The facility did not provide required training on effective communication to five direct care staff, including nurse aides, an LPN, and an RN, as mandated by facility policy. Review of education records and staff interviews confirmed the absence of this training for the staff reviewed.
The facility did not provide required QAPI training to five direct care staff members, including nurse aides, an LPN, and an RN, as mandated by facility policy and state regulations. This was confirmed through review of training records and staff interviews.
Two direct care staff members, an LPN and an RN, did not receive mandatory infection control training as required by facility policy. Review of education records confirmed the absence of this training for these staff, which was acknowledged by facility leadership.
The facility did not notify physicians or resident representatives of changes in condition or status for three residents, including incidents where a resident left the unit, another was found without a required monitoring device, and a third had a new medication order. Staff interviews confirmed that required notifications were not made in these cases.
A facility failed to inform a resident's representative about a medication dosage increase for a resident with moderate cognitive impairment and multiple diagnoses, including end-stage renal disease and dementia. The facility did not discuss the risks, benefits, or alternatives of the increased Mirtazapine dosage, as confirmed by the DON.
The facility failed to communicate necessary resident information to the receiving health care provider for two residents transferred to the hospital. This included missing details such as care plan goals, advanced directive information, and specific instructions for ongoing care. The Director of Nursing confirmed the oversight, which violated regulatory requirements for transfer and discharge.
The facility failed to provide written notification of the bed-hold policy to two residents during their hospital transfers, as required by regulations. Despite the facility's policy to inform residents at admission and transfer, documentation was missing for both cases. The DON confirmed the oversight.
The facility failed to provide necessary ADL assistance for two residents. One resident, with a partial-moderate need for assistance, did not receive a shower on a specific date. Another resident, with a substantial maximal need for assistance, missed multiple showers in January. The DON confirmed these deficiencies.
The facility failed to notify the Department of Health about a COVID-19 outbreak affecting 36 residents. The DON mistakenly believed only employee cases needed reporting, leading to non-compliance with health department notification requirements.
A resident with dementia and a history of elopement risk left the facility unsupervised after a staff member used an ID badge to override the security system, allowing the resident to exit with visitors. The security alarm was triggered, but the resident was already outside. The facility failed to properly identify the resident, leading to the unsupervised exit.
A resident with a history of nervous system degeneration, diabetes, and epilepsy eloped from the facility and was found in the parking lot. The facility failed to notify the State Agency of this reportable event in a timely manner, as confirmed by the DON.
A facility failed to provide necessary ADL assistance to a resident who was dependent on help for self-care tasks. Despite the resident's MDS assessment indicating full dependency, records showed missed showers on multiple occasions. This deficiency was confirmed by the Nursing Home Administrator.
A resident with a history of chronic pain experienced chest pain and requested Oxycodone. Despite the facility's policy requiring notification of a medical provider for significant changes in condition, the LPN did not notify a physician or take a full set of vitals. The Director of Nursing confirmed the failure to follow protocol.
A resident with a history of stroke and Multiple Sclerosis was neglected by a Nurse Aide (NA) who failed to change the resident before a scheduled MRI appointment, despite the resident's request. The resident returned from the appointment heavily soiled, with dried bowel movement from back to knees, indicating prolonged neglect. The incident was confirmed by staff and led to the termination of the responsible NA.
A facility failed to protect two residents from medication misappropriation by an RN, who diverted six doses of oxycodone. The facility's policies on controlled substances and prevention of misappropriation were not followed, as discrepancies in medication records and lack of co-signatures for destroyed medications were found. The Director of Nursing confirmed the unaccounted narcotics, highlighting the failure to safeguard residents.
The facility failed to store food products properly in the Main Kitchen, risking foodborne illness. An observation revealed unsealed plastic bags of rice and pureed bread mix in open boxes, contrary to the facility's policy requiring opened containers to be dated and sealed. This was confirmed by the Dietary Director.
The facility failed to maintain resident dignity and communication by not providing privacy during medication administration, lacking a communication plan for a resident with language barriers, and not respecting a resident's preferred name. A resident received medication without privacy, another struggled with communication due to language barriers, and a third was not addressed by her preferred name.
The facility failed to document a physician's discharge order for a resident and did not communicate necessary information to receiving health care providers for five residents transferred to a hospital. These residents had various medical conditions, and the lack of adherence to facility policies on discharge and transfer documentation was confirmed by the DON.
Failure to Maintain Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain resident dignity by not covering urinary catheter bags for two residents. One resident had a urinary catheter bag hanging on the bedframe while in bed, and the bag was observed uncovered. The resident’s record showed diagnoses of hypertension, benign prostate hyperplasia, and anxiety. A registered nurse confirmed the catheter bag was not covered as required. Another resident with diagnoses of anemia, high blood pressure, and obstructive uropathy was observed lying in bed with a urinary catheter bag filled with urine that was also not covered, and a nurse aide confirmed the bag was not covered as required. The facility also failed to provide bodily privacy during a wound care treatment for another resident. That resident’s record showed diagnoses of high blood pressure, wound infection, and muscle weakness, and a physician order directed daily wound care to both heels. During the wound care observation, the wound care RN did not close the door or pull the privacy curtain while performing treatment. The RN later confirmed that bodily privacy was not provided during the treatment procedure.
Missing Orders and Notification for Blood Sugar Management and Condom Catheter
Penalty
Summary
The facility failed to obtain physician orders for management of hypoglycemia for one resident with diabetes, failed to obtain physician orders for both hypoglycemia and hyperglycemia parameters for another resident with diabetes, failed to notify a physician after a hypoglycemic episode for one resident, and failed to obtain an order for a urinary condom catheter for another resident. Review of facility policies showed that the diabetes protocol required physician-set parameters for blood sugar monitoring and reporting, and the condom catheter policy required verification of a physician order. The report identified Resident R173, admitted with diabetes, hypertension, and hyperlipemia, whose insulin sliding-scale order did not include hypoglycemia parameters. Nursing notes documented that the resident was sweating, had a blood sugar of 65, and was placed on a hypoglycemic protocol, but the note did not show that the physician was notified. An RN confirmed the order lacked hypoglycemia parameters and that the physician was not notified of the episode. The report also identified Resident R15, admitted with hypertension, diabetes, and depression, whose insulin lispro sliding-scale order included only blood sugar ranges for insulin coverage and did not include parameters for hypoglycemia or hyperglycemia. An RN confirmed that the order lacked both sets of parameters. In addition, Resident R185, admitted with hypertension, BPH, and anxiety, was observed in bed with a urinary catheter bag hanging on the bedframe, and admission documentation noted the resident was continent of bladder and included a genitourinary note of "condom catheter." The clinical record did not contain an order for the urinary condom catheter, and an RN confirmed that no physician order was present and that the catheter had been left on by staff.
Incomplete dialysis communication and access site monitoring
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents who required dialysis services. Resident R17 had ESRD, was ordered to receive hemodialysis Monday, Wednesday, and Friday, and had a care plan calling for dialysis communication and monitoring of the AV fistula. The resident’s clinical record did not include complete dialysis communication forms on six dates between 5/1/26 and 6/22/26, and an LPN confirmed the missing documentation during interview. Resident R34 had ESRD and was ordered to send a communication binder to dialysis on Tuesday, Thursday, and Saturday, with communication sheets completed upon return every day and evening shift; the dialysis communication record was incomplete on 6/9/26, 6/11/26, and 6/13/26. Resident R86 had quadriplegia, diabetes mellitus, and dependence on renal dialysis, with orders for dialysis Monday, Wednesday, and Friday and to send the dialysis communication book on dialysis days; the communication binder was incomplete on 6/10/26, 6/15/26, 6/20/26, and 6/22/26. The facility also failed to ensure accurate and complete monitoring of dialysis access sites for two residents. Resident R17 had conflicting physician orders identifying both right and left AV fistula monitoring, and the DON stated the resident had a fistula in the left arm and that the orders were updated to be accurate. The June 2026 TAR did not show documentation that the ordered AV fistula checks for bruit and thrill were completed or refused on multiple shifts. The DON confirmed the facility failed to ensure monitoring of Resident R17’s dialysis access site was accurate and complete. Resident R86 had a physician order for right AV fistula thrill checks every shift and bruit checks every shift, with notification to the physician if not present. The June 2026 TAR did not show documentation that thrill or bruit checks were signed off or refused on multiple daylight shifts and on two evening shifts. During interview, the DON confirmed the facility failed to document dialysis-specific care as ordered for Resident R86. The NHA and DON later confirmed that the facility failed to provide consistent and complete communication with the dialysis center for all three residents and failed to ensure access site monitoring was completed for two of the three residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in the facility’s medication storage areas, including the 4th Floor Medication Room and four medication carts. Review of the facility policy stated that medications maintained in the facility must be properly labeled in accordance with current state and federal guidelines, including expiration dates when applicable. During observation of the 4 [NAME] Medication Cart, multiple opened medications were found without required dates, including inhalers, eye drops, insulin pens, liquid ibuprofen, Peridex rinse, bismuth, Tylenol liquid, Voltaren gel, Ipratropium Bromide, tacrolimus ointment, and a Ventolin inhaler stored in a cup. Some medications were also stored improperly, including Voltaren gel and tacrolimus ointment with oral medications, and one insulin glargine pen not stored in a bag as required. Additional observations showed the 2 [NAME] Medication Cart contained Budesonide, Latanoprost, and Timolol without expiration dates; the 3 [NAME] Medication Cart contained Ipratropium nebulizer solution without an expiration date and an unopened Lantus insulin vial labeled for refrigeration but missing an expiration date; the 4th Floor Medication Room refrigerator contained an opened bottle of Tubersol solution without a date; and the 2 East Medication Cart contained albuterol nebulizer solution without an expiration date. RN and LPN staff interviewed during the observations confirmed the medications were missing required dates and that the storage issues were present.
Infection Control Failures in Refrigerator Monitoring, Laundry Handling, Wound Care, and Water Management
Penalty
Summary
The facility failed to properly monitor a resident personal refrigerator for one of two refrigerators in a resident room. Resident R98, who was admitted with anemia, COPD, and diabetes, was observed in bed with a personal refrigerator in the room that did not have the required temperature log for June 2026. The resident stated they would have to get a log for June 2026, and the Unit Manager confirmed that the refrigerator had not been properly monitored as required. The facility also failed to handle linens in a safe and aseptic manner in the main laundry room when a laundry worker was observed loading clean linens into a dryer and a washcloth fell to the floor. The worker picked up the washcloth from the floor and placed it back into the dryer with the clean linens. In addition, during a dressing change for Resident R10, who had diagnoses including high blood pressure, wound infection, and muscle weakness, the wound care RN did not establish a clean field using the bedside stand and placed a trash can liner on the sheet at the foot of the bed, then placed opened wound care supplies on the liner during treatment. The facility also failed to implement a comprehensive water management program for Legionella, as the program only indicated annual culture testing for ice machines and the NHA stated there was no proof of Legionella testing for 2025, only 2024 results.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe for one resident to self-administer medications. Review of the facility policy on self-administration of medications indicated that the facility should assess whether self-administration is safe and clinically appropriate based on the resident’s functionality and health condition, and that orders for self-administration should list the specific medications the resident may self-administer. The resident’s clinical record did not include an assessment or physician order to self-administer medications. The resident was admitted to the facility and had diagnoses of heart failure, high blood pressure, and diabetes. During an observation, the resident was sitting in bed with a bedside table pulled close, and a container of fluticasone nasal spray and an albuterol inhaler were on the table. Neither medication was stored in a bag, and neither was labeled with the date opened. The resident stated they preferred to keep the medications at bedside so they would not have to wait for nursing staff when needed. The Unit Manager confirmed the record lacked an assessment or physician order and that the facility failed to determine whether self-administration was safe for the resident.
Failure to Notify Family of New Behavioral Concern
Penalty
Summary
The facility failed to notify the resident’s family of behavioral concerns for one of three closed resident records, CR194. The facility policy on changes in a resident’s condition or status stated that the resident, attending physician, and resident’s representative are to be promptly notified of changes in medical or mental condition and status. CR194’s record showed diagnoses including Parkinson’s disease, chronic kidney disease, Sjogren syndrome, acute Lyme disease, and altered mental status. Clinical notes documented that on 5/5/26 she was pacing in the hallways, stating she wanted to leave and would sleep on the floor if staff would not let her leave, and the physician and family were notified at that time. Later documentation and staff interviews identified a new behavior in which CR194 would kneel on the floor while wandering the nursing unit, but her clinical nurse notes and physician documentation did not include notifications about this behavior. A facility investigation noted that a social worker observed her randomly kneel in the hallway and stand back up three times, and staff stated she did this in the evenings. Interviews with the speech therapist, social worker, and RN confirmed the behavior was observed, was not care planned, and that staff were aware of it, but the record did not show family notification for this behavioral concern.
Failure to Assess Mattress Bolster as a Possible Restraint
Penalty
Summary
The facility failed to assess the functional status of Resident R23 to determine whether the use of a bolster on the mattress was a restraint. Facility policy defined physical restraints as any method or device attached to or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to the body. Resident R23’s record showed admission to the facility, diagnoses of high blood pressure, dementia, and anemia, and a physician order for a bolster mattress to bed dated 12/23/24. Resident R23’s care plan identified the resident as high risk for falls related to confusion, psychoactive drug use, a history of a fall at home with left hip fracture, and poor balance and safety awareness, with interventions including bolsters to bed when in bed. During observation on 6/23/26 at 9:47 a.m., Resident R23 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. The clinical record did not identify any assessments or ongoing evaluations for the use of bolsters on the resident’s mattress, and a Unit Manager confirmed on 6/26/26 at 9:26 a.m. that the facility failed to assess whether the bolster was a restraint for the resident.
Failure to Update Care Plan for New Wandering and Kneeling Behavior
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect the current care needs and services for Closed Resident Record CR194. The resident was admitted with diagnoses including Parkinson’s disease, chronic kidney disease, Sjogren syndrome, acute Lyme disease, and altered mental status. Her MDS dated 5/5/26 documented these conditions, and clinical notes on 5/5/26 described her pacing in the hallways, stating she wanted to leave and that if staff would not let her leave, she would sleep on the floor. The physician was notified and the family was called. The care plan dated 5/7/26 addressed high fall risk and impaired mobility, but the record did not include care plans for the resident’s later behavior of purposefully kneeling on the floor while wandering the nursing unit. Additional documentation showed that on 5/13/26 the physician noted the resident reported staff told her she was wandering at night, though she did not recall it. On 5/20/26, she was documented as confused with no witnessed unwanted behaviors, and on 5/21/26 she was discharged from the facility. The facility investigation dated 5/29/26 stated a social worker observed the resident randomly kneel while walking in the hallway and stand back up three times, and nursing staff said she did this in the evenings. During interviews, the speech therapist stated he saw her place one knee and then both knees on the hallway floor and said it was not care planned, while the social worker stated staff were already aware of the behavior and were redirecting her. An RN stated that when residents have new behaviors, the family is notified and the care plan is updated, but that did not occur for this behavior in the record reviewed.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
Proper treatment for pressure ulcers was not provided for one resident with bilateral heel pressure injuries. Resident R10 was admitted with diagnoses including high blood pressure, wound infection, and muscle weakness. The resident’s comprehensive care plan identified impaired skin integrity related to a deep tissue injury present on admission and stage 3 pressure injuries to both heels. The care plan directed use of purple offloading boots at all times while in bed, except for care and skin checks, and wound care per physician orders. A physician order dated 5/2/26 directed treatment to the left medial heel with Dakins, Medihoney, calcium alginate, ABD, and Kerlix every day shift, and a similar order directed treatment to the right heel. Review of the May and June 2026 TAR showed these wound treatments were not signed off as completed or refused on multiple shifts for both heels. A later physician order dated 5/18/26 directed purple heel relief boots to both feet while in bed, but the TAR showed the boots were not signed off as completed or refused on multiple shifts. During interview, the DON confirmed the facility failed to make certain the resident received proper treatment for pressure ulcers.
MRR Not Reviewed by Physician
Penalty
Summary
The facility failed to provide documentation that medication regimen reviews were completed and reviewed by the resident's attending physician monthly for one of five residents, Resident R3. The facility policy on Medication Regimen Review stated that the consultant pharmacist performs a comprehensive MRR at least monthly and provides a written report to the attending physicians within 24 hours for each resident identified as having a non-life threatening medication irregularity. Resident R3 was admitted to the facility with diagnoses of anemia, atrial fibrillation, and high blood pressure. Review of Resident R3's MRRs showed that the reviews dated 1/9/26, 2/25/26, 3/29/26, 5/14/26, and 5/27/26 were signed by a Physician Assistant rather than the physician as required. During interview on 6/24/26 at 1:19 p.m., the DON confirmed that the Physician Assistant signed Resident R3's MRRs instead of the physician.
Incomplete Investigation of Resident Burn Injury
Penalty
Summary
The facility failed to initiate a thorough investigation after Resident R2 sustained a burn to both hands from hot coffee during the 3-11 shift. Documentation stated the burn caused a red area and blister, and the on-call physician recommended that the resident be sent to the hospital for evaluation and treatment, but the resident refused. Resident R2’s MDS dated 4/17/26 listed diagnoses of mood disorder, brain injury without loss of consciousness, and dysphagia. During interview, the Dietary Manager stated the facility does not take temperatures of coffee or hot water before or during tray line service and had no coffee temperature documentation from the date of the incident. Review of the facility investigation showed it did not include a summary of findings, witness statements, or employee and resident interviews regarding how the injury may have occurred, and the DON confirmed the investigation was not completed thoroughly.
Missing Colostomy Orders
Penalty
Summary
The facility failed to have physician orders for colostomy supplies and care for one resident who was admitted with diagnoses including malignant neoplasm vulva, colostomy, and anxiety. The resident’s MDS 5-Day assessment dated 5/6/26 indicated the diagnosis remained current. Physician orders dated 5/26/26 included colostomy appliance change every 7 days and as needed, a Conva Tec Natura Plus pouch, and colostomy care every shift, but during an interview on 6/2/26 at 2:30 p.m., the DON confirmed the facility failed to write colostomy orders on admission as required.
Unsafe Hot Beverage Service Resulted in Resident Burn
Penalty
Summary
The facility failed to ensure a safe environment when Resident R2 burned both hands on hot coffee during the 3-11 shift. Documentation stated the coffee caused a red area and a blister, including an intact blister on the second finger knuckle to the top of the right hand measuring approximately 2 cm by 2 cm. Resident R2 was admitted with diagnoses including mood disorder, brain injury without loss of consciousness, and dysphagia. Facility records showed the coffee temperature at tray set-up was 168.7 degrees Fahrenheit, and a test tray evaluation documented the coffee temperature at 147.3 degrees Fahrenheit when served on the unit after 18 minutes, with a 21.4-degree Fahrenheit temperature loss. The facility investigation stated coffee from the kitchen was approximately 172 to 178 degrees Fahrenheit at tray set-up, with an estimated temperature loss of 30 to 40 degrees during delivery to units and rooms. The DON stated Resident R2 did not report the spill until later that evening and refused hospital transfer. The NHA confirmed the facility failed to ensure a safe environment resulting in a burn for one of three residents.
Failure to Investigate Incidents and Complete Staff Background Checks
Penalty
Summary
The facility failed to implement and follow its own written policies and procedures regarding the prevention, identification, and investigation of abuse, neglect, and misappropriation of resident property. Specifically, the facility did not conduct a complete and thorough investigation of incidents involving two residents. One resident sustained abrasions to the toes after their right foot was dragged on the carpet while being pushed in a shower chair, but this incident was not documented or investigated as required by facility policy. Another resident, who had diagnoses including hypertension, cancer, and hyperlipidemia, was found on a different floor without their required monitoring device, indicating a potential elopement. This incident was also not documented or investigated, and the DON was unaware of the event. Additionally, the facility failed to conduct required state criminal background checks prior to the start of employment for two nursing staff members, an LPN and an RN. Personnel records for both staff members did not include completed background checks before their hire dates, contrary to facility policy and regulatory requirements. The Human Resources staff and the Nursing Home Administrator confirmed that these checks should have been completed prior to employment but were not. These deficiencies were identified through a review of facility documents, policies, clinical records, and staff interviews. The facility's failure to follow its own policies and regulatory requirements resulted in uninvestigated incidents involving potential neglect and incomplete staff background screening.
Failure to Investigate and Document Incidents of Possible Abuse or Neglect
Penalty
Summary
The facility failed to identify and investigate incidents of possible abuse and/or neglect for three residents. For one resident with hypertension, diabetes, and hyperlipidemia, abrasions were noted on the right toes after the foot was dragged on the carpet while being pushed in a shower chair. This incident was documented in the physician's progress note, but there was no corresponding entry or investigation in the facility's incident records, and the Nursing Home Administrator confirmed that no investigation was conducted as required by policy. Another resident with diabetes, post-traumatic stress disorder, and hypotension was found attempting to leave the facility on two separate occasions, including being recovered from the front door by staff. Despite these events, no investigation was conducted. A third resident with hypertension, cancer, and hyperlipidemia was found on the first floor without the required watchmate device on their wheelchair, as ordered. The Director of Nursing was unaware of this elopement, and the incident was not documented or investigated. These failures were confirmed by facility leadership during interviews.
Failure to Update Care Plans for Changes in Resident Condition
Penalty
Summary
The facility failed to update and revise care plans to reflect the specific care needs of three residents following significant changes in their health status. For two residents who tested positive for Norovirus, the care plans did not include goals or interventions related to their positive Norovirus status, despite physician documentation and lab results confirming the diagnosis. Additionally, another resident with a new physician order for an indwelling urinary catheter did not have corresponding goals or interventions added to their care plan to address this new care need. These deficiencies were confirmed through review of facility documents, clinical records, and staff interviews. The Director of Nursing and a Registered Nurse acknowledged that the care plans were not revised as required to address the residents' updated conditions, including Norovirus infection and the use of an indwelling urinary catheter. The facility's own policy requires ongoing assessment and revision of care plans as residents' conditions change, which was not followed in these cases.
Failure to Follow Physician Orders and Treatment Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with an intravenous (IV) catheter, there was no physician order for IV dressing changes, and the dressing was observed to be loosened and half peeled away with an outdated change date. Staff confirmed that the dressing had not been changed as required by facility policy, which mandates dressing changes at least every seven days or when soiled, damp, or loose. Another resident with bilateral below-the-knee amputations had physician orders for daily wound care, including cleansing and application of antibiotic ointment dressings to both stumps. However, observation revealed that one stump had a dressing dated two days prior, and the other stump had no dressing in place. Staff confirmed that the treatments were not completed as ordered. Additionally, two residents did not have timely follow-up physician appointments ordered or scheduled as required, despite documented physician orders for follow-up with specialists such as urology, neurology, and endocrinology. Staff interviews confirmed that these appointments had not been made. Furthermore, a resident with an order for a daily lidocaine patch did not have the patch labeled with the date and time of application during a medication pass, as required by facility policy. The LPN administering the medication confirmed the omission. These findings demonstrate failures to follow physician orders, maintain proper documentation, and adhere to facility policies for treatment and care.
Failure to Properly Store CPAP/BIPAP Masks for Multiple Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents who required CPAP/BIPAP therapy. According to facility policy, CPAP/BIPAP masks are to be bagged when not in use, and staff are to document how residents tolerate the procedure. For all three residents, observations on two consecutive days revealed that their CPAP masks were left lying unbagged on their bedside tables, contrary to policy requirements. These findings were confirmed by a registered nurse during interviews. The residents involved had significant medical histories, including chronic obstructive pulmonary disease, diabetes, high blood pressure, stroke, hemiplegia, and anemia, and all had physician orders and care plans specifying the use and maintenance of CPAP/BIPAP equipment. Despite clear physician orders and care plan instructions regarding the application, cleaning, and storage of CPAP/BIPAP equipment, staff did not ensure that the masks were properly bagged when not in use. The Director of Nursing confirmed the failure to provide appropriate respiratory care for these residents. The deficiency was cited under state regulations concerning the responsibility of the licensee, resident care policies, and nursing services.
Deficient Dialysis Communication, Orders, and Care Planning
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two of three residents reviewed, as evidenced by numerous incomplete or missing dialysis communication records. Specifically, one resident with end stage kidney disease, diabetes, and anxiety had over twenty days of missing or incomplete communication records with the dialysis center, while another resident had fourteen days of incomplete or missing records. Staff interviews, including those with an LPN, RN, and the Director of Nursing, confirmed these lapses in communication documentation. Additionally, the facility did not have physician orders for the care and management of dialysis access devices for two residents. One resident with a right upper arm fistula and another with a tessio catheter did not have corresponding physician orders for access site care. Furthermore, care plans for these residents were incomplete, failing to specify the type and location of the access device or omitting care and management instructions altogether. These deficiencies were confirmed by the Director of Nursing and were not in accordance with the facility's own policy or regulatory requirements.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple instances where medications and biologicals were not stored or labeled according to facility policy and accepted professional standards. On the Third floor [NAME] Hall medication cart, an open Toujeo insulin pen was found without a cap, not labeled with the date opened, and not stored in a bag. Additionally, Humalog and Lantus insulin pens were not labeled with the date opened, and one Lantus pen lacked a resident identifier. These findings were confirmed by an LPN during the survey. On the Third floor North Hall medication cart, a bottle of Miralax was not labeled with the date opened, and two tubes each of Banophen anti-itch cream and Voltaren gel were present, which staff confirmed should have been stored in the treatment cart, not the medication cart. On the Fourth floor East Hall medication cart, a Lispro insulin vial was not dated, and Tramadol was found in a bag with an empty pharmacy container and several clear pouches containing pills, which staff stated was done for ease of counting. The DON confirmed that medications and biologicals were not stored properly and securely in three of five medication carts reviewed.
Failure to Implement Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to follow its own infection prevention and control policies, as well as CDC guidelines, in several key areas. Two residents with indwelling medical devices (tessio catheters for dialysis) did not have physician orders or care plan interventions for Enhanced Barrier Precautions (EBP) as required. Observations confirmed the absence of EBP signage and documentation for these residents, and the Director of Nursing acknowledged the omission. Both residents had significant medical histories, including end stage kidney disease and dependence on dialysis, which necessitated the use of indwelling catheters. Additionally, the facility did not implement appropriate transmission-based (Contact) precautions for four residents who tested positive for norovirus. Despite positive lab results and physician documentation indicating concern for norovirus, there was no evidence in the clinical records that these residents were placed on Contact Precautions as required by facility policy and CDC guidelines. The Infection Preventionist confirmed that these precautions were not implemented for the affected residents. The facility also failed to maintain an ongoing infection surveillance program, as required by its own policies and the job description of the Infection Preventionist. Infection control documentation was missing for two out of ten months, and the DON confirmed the lack of surveillance during those periods. Furthermore, during a medication pass, an LPN was observed removing and applying a lidocaine patch to a resident without using gloves, which was confirmed by the staff member. This failure to use appropriate personal protective equipment during medication administration represents a lapse in infection control practices.
Failure to Report Neglect Allegation to State Authorities
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident to the State Department of Health as required by policy and regulation. The facility's policies mandate that all incidents of abuse, neglect, or misappropriation, including injuries of unknown origin, must be reported to the appropriate authorities and thoroughly investigated. However, a review of the facility's incident records did not include documentation regarding a resident's right foot skin concerns, which were caused when the resident's right foot was dragged on the carpet while being pushed in a shower chair, resulting in several faint, scabbed areas on three toes. The resident involved had diagnoses of hypertension, diabetes, and hyperlipidemia. The incident was documented in the physician's progress note, but there was no evidence that it was reported to the State Department of Health. During an interview, the Nursing Home Administrator confirmed that the incident was not reported as required. This failure to report was identified through a review of facility policies, clinical records, and staff interviews.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in elopement incidents involving two residents. According to the facility's Wandering and Elopements policy, residents at risk for unsafe wandering should be identified and protected from harm. One resident, with a history of diabetes mellitus, post-traumatic stress disorder, and hypotension, was assessed as moderately cognitively impaired but not at risk for elopement. Despite this, the resident was able to access the elevator and reach the lobby and front door without staff knowledge, and on another occasion attempted to exit the facility. Another resident, also moderately cognitively impaired and diagnosed with hypertension, cancer, and hyperlipidemia, was identified as at risk for elopement. Physician orders required a security bracelet to be attached to the resident's wheelchair at all times, with checks every shift. However, the resident was found on a different floor without the required alarm device on the wheelchair, contrary to the care plan and physician orders. The Nursing Home Administrator confirmed that the facility did not provide proper supervision for these residents as required.
Failure to Document Clinical Indication for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that appropriate treatments and services were provided for the use of an indwelling urinary catheter for one resident. Specifically, the clinical record for a resident admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness showed a physician's order for an indwelling urinary catheter, but the order did not include a required diagnosis for the catheter. Review of facility policy indicated that clinical indications for catheter use should be reviewed and documented prior to insertion, and the ongoing need for the catheter should be assessed and documented by nursing and the interdisciplinary team. This deficiency was confirmed during an interview with a registered nurse, who acknowledged the failure to provide the required documentation and assessment for the catheter use.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five nursing staff members, as required by facility policy. Personnel records for two nurse aides and one LPN, with varying hire dates, did not contain documentation of annual performance evaluations. The facility's policy specifies that employee performance should be rated, strengths and areas for improvement noted, and the evaluation filed in the personnel record. During an interview, the Nursing Home Administrator confirmed that these evaluations had not been completed for the identified staff members.
Failure to Accommodate Documented Seafood Allergy in Resident Meal Service
Penalty
Summary
Resident R13, who had documented diagnoses including anoxic brain damage, cerebral infarction, and chronic obstructive pulmonary disease, was admitted to the facility with a known and recorded allergy to crab and seafood. Despite this, the resident was served shrimp alfredo for dinner, as confirmed by a review of the nutrition assessment, physician orders, and dietary manager interview. Following the meal, the resident vomited, with whole dinner contents present, and later reported the incident to staff. The resident's granddaughter also filed a grievance, expressing concern that seafood was served despite the known allergy. The deficiency was identified through observation, record review, and staff interviews, confirming that the facility failed to provide food in a form that met the resident's individual dietary needs.
Failure to Ensure Resident Capacity and Proper Signatures for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement and failed to obtain required signatures for such agreements. For one resident with a diagnosis of non-Alzheimer's dementia, hyperlipidemia, and anxiety, the Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 6, signifying severe cognitive impairment. Despite this, the resident personally signed a binding arbitration agreement, indicating the facility did not verify the resident's capacity to comprehend the agreement at the time of signing. The admissions director confirmed this lapse during an interview. Additionally, another resident with diagnoses including high blood pressure, weakness, and dementia, and a BIMS score of 14 (cognitively intact), was documented as having entered into a binding arbitration agreement. However, a review of the facility's records showed that the required signature was not obtained for this agreement. The admissions director also confirmed this failure to secure the necessary signature. These findings were based on reviews of facility documents, resident clinical records, and staff interviews.
Failure to Ensure Required QAA Committee Members Present at Quarterly Meeting
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members present, as evidenced by a review of facility policy, QAA attendance records, and staff interviews. Specifically, for the first quarter of 2025, the attendance records did not show that the Infection Preventionist was present at the QAA meeting. This was confirmed by the Director of Nursing during an interview, who acknowledged that the required quarterly meeting did not include all mandated committee members for that quarter. The facility's QAPI policy requires an ongoing, facility-wide, data-driven program focused on care outcomes and quality of life, and mandates quarterly QAA meetings with specific committee members, including the Infection Preventionist. The absence of the Infection Preventionist at the required meeting constituted noncompliance with both facility policy and regulatory requirements.
Failure to Monitor Antibiotic Use for One Month
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one of ten months, specifically September 2024. Review of the facility's infection control policies and procedures, as well as the job description for the Quality Assurance/Infection Control Preventionist, indicated that monitoring antibiotic use is a required responsibility. However, documentation of antibiotic monitoring was missing for September 2024 in the facility's Infection Control surveillance records covering August 2024 through May 2025. During an interview, the Director of Nursing confirmed that antibiotic stewardship was not carried out for that month.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing infection prevention and control programs and activities from 2/10/25 to 3/5/25. According to staff interviews and facility records, the previous Infection Preventionist resigned effective immediately on a Saturday, and a new Infection Preventionist was assigned to the role. However, the newly assigned Infection Preventionist did not complete the required specialized training and certification in infection prevention and control until 3/6/25. The Director of Nursing confirmed that during this period, there was no qualified individual overseeing the infection prevention and control program, as required by facility policy and state regulations.
Failure to Maintain Crash Carts in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential emergency equipment, specifically two crash carts located on the first and second floors, were maintained in safe operating condition. Observations revealed that the Crash Cart Daily Signature Log for the first-floor crash cart had not been completed for three consecutive days, with the last entry dated three days prior to the observation. Similarly, the second-floor crash cart log was missing an entry for the same date, with the signature line left blank. These lapses were confirmed by both the Director of Nursing and a Registered Nurse during interviews, who acknowledged that the required daily audits had not been conducted as documented.
Failure to Provide Required Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication to all five direct care staff members reviewed, including nurse aides, an LPN, and an RN. According to the facility's own in-service training policy, all staff are required to participate in both initial orientation and annual in-service training, which must include effective communication as a core topic. However, a review of education records for the year 2024 showed that none of the five staff members had documentation of having received this training. Interviews with the Human Resources Director confirmed that education is scheduled annually, and the Nursing Home Administrator acknowledged the lack of communication training for the staff in question. The deficiency was identified through a review of facility policy, staff education records, and staff interviews, and it was cited under 28 Pa. Code: 201.14(a) and 201.20(a) for failure to meet staff development requirements.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) to all staff as required by its own policy and state regulations. Review of the facility's in-service training policy indicated that all staff must participate in initial orientation and annual in-service training, with QAPI listed as a required topic. However, examination of facility education records for the year 2024 revealed that five direct care staff members, including nurse aides, an LPN, and an RN, did not receive training on QAPI. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that the facility did not provide QAPI training to these staff members. The deficiency was identified through review of facility documents and staff interviews, and it was determined that the facility was not in compliance with its own policies and state regulations regarding staff development and management responsibilities.
Failure to Provide Required Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to two of five direct care staff members reviewed, specifically an LPN and an RN. According to the facility's in-service training policy, all staff are required to participate in initial orientation and annual in-service training, which must include infection prevention as a topic. Review of facility education records for the year 2024 showed that neither the LPN nor the RN had documentation of having received infection control training. This was confirmed by the Human Resources Director and the Nursing Home Administrator during interviews. The deficiency was cited under 28 Pa Code: 201.14 (a) and 28 Pa Code: 201.18 (b)(1).
Failure to Notify Physician or Representative of Resident Status Changes
Penalty
Summary
The facility failed to notify the physician or resident representative of changes in condition or status for three residents, as required by facility policy. For one resident with diabetes, PTSD, and hypotension, there was no documentation of physician or representative notification after the resident left the unit and was found near the front door by nursing staff. Another resident with hypertension, cancer, and hyperlipidemia was found on a different floor without the required monitoring device on their wheelchair, and again, there was no evidence of notification to the physician or representative regarding this incident. A third resident, who had high blood pressure, bilateral below-knee amputations, renal insufficiency, and severe cognitive impairment, had a new medication order for pantoprazole due to a history of gastrointestinal bleeding. The clinical record did not show that the resident's representative was notified of this medication change. Staff interviews confirmed that in all three cases, the required notifications to physicians or resident representatives were not made following changes in the residents' conditions or status.
Failure to Inform Resident's Representative of Medication Change
Penalty
Summary
The facility failed to inform a resident's representative in advance of the proposed care, including the risks and benefits of a prescribed medication change for a resident. The resident, who had diagnoses of end-stage renal disease, dementia, and chronic kidney disease, was assessed with a BIMS score of 10, indicating moderate cognitive impairment. A physician's order increased the dosage of Mirtazapine from 30 mg to 45 mg at bedtime for mood management. However, there was no evidence in the nurse's progress notes that the resident's daughter or other representatives were notified of this new order or that the advantages, disadvantages, and alternative options were discussed. The Director of Nursing confirmed during an interview that the facility did not inform the resident's representative about the proposed care changes as required. This oversight was identified during a review of clinical records and staff interviews, highlighting a failure to comply with resident rights and nursing services regulations. The deficiency was noted under the Pennsylvania Code, specifically 28 Pa Code 201.29(j) regarding resident rights and 28 Pa. Code 211.12(d)(1) concerning nursing services.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility was found to be non-compliant with the requirements for transfer and discharge under 42 CFR Part 483, Subpart B, as well as the 28 Pa. Code, during an abbreviated survey conducted in response to complaints and an infection control survey. The deficiency was identified in the facility's failure to communicate necessary resident information to the receiving health care provider for two residents who were transferred to the hospital. This lack of communication included the omission of critical details such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The first resident, admitted to the facility in January 2025, had a medical history that included high blood pressure, diabetes, and cerebral infarction. This resident was transferred to the hospital shortly after admission, but the facility did not document or communicate the necessary information to the hospital, which was essential for the resident's continued care. Similarly, the second resident, admitted in October 2023, with diagnoses of depression, dementia, and Parkinson's disease, was also transferred to the hospital without the required documentation and communication of care details. During an interview, the Director of Nursing confirmed the facility's failure to ensure that the necessary information was communicated to the receiving health care provider for both residents. This oversight was a direct violation of the regulatory requirements for transfer and discharge, as it did not provide the receiving facility with the information needed to meet the residents' specific needs and ensure a safe and effective transition of care.
Plan Of Correction
1. Residents R1 returned to the facility on 1/15/25 and discharged home with family on 2/3/25, and R2 returned to the facility on 1/27/25. 2. A one-week retroactive review of all facility-initiated transfers will be followed-up by telephone to ensure that all necessary resident information was communicated to the receiving health care provider and provide any information if necessary. 3. The NHA or designee will educate all licensed nursing staff and social services staff on the necessary information requirement found at F622 for transfers to a receiving health care provider. 4. The NHA or designee will audit all facility-to-facility transfers to ensure all resident information requirements were met daily x3, then five resident facility-to-facility transfers weekly x8. Results will be reviewed through QAPI for further recommendation.
Failure to Notify Residents of Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by §483.15(d). This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 5/12/24, mandates that residents or their representatives receive written information about the bed-hold policy at admission and at the time of transfer. However, for two residents, this requirement was not met during their respective hospital transfers. Resident R1, admitted on 1/13/25, was transferred to the hospital on 1/14/25 and returned on 1/15/25. The clinical record lacked evidence of written notification about the bed-hold policy at the time of transfer. Similarly, Resident R2, admitted on 10/23/23, was transferred to the hospital on 1/21/25 and returned on 1/27/25, with no documented evidence of notification. The Director of Nursing confirmed the oversight during an interview, acknowledging the failure to provide the required notifications for both residents.
Plan Of Correction
1. Resident R1 returned to the facility on 1/15/25 and resident R2 returned to the facility on 1/27/25. No negative outcomes to R1 and R2. No charges made to R1 and R2 accounts for bed-hold fees. 2. A retroactive 14-day review of all hospital/leave transfers will be completed to ensure resident/representatives have been provided information regarding the facility bed-hold policy. 3. NHA or designee will educate all licensed nursing staff and social services staff on the facility bed-hold policy and communicating information at time of transfer. 4. NHA or designee will audit all hospital/leave transfers daily x3, then five resident transfers weekly x8 to ensure bed-hold information was provided. Results will be reviewed through QAPI for further recommendation.
Failure to Provide ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, resulting in a deficiency. Resident R1, who was admitted on January 13, 2025, had a Minimum Data Set (MDS) assessment indicating a partial-moderate need for assistance with self-care activities such as bathing, dressing, and using the toilet. Despite this, documentation showed that Resident R1 did not receive a shower on January 25, 2025. Similarly, Resident R3, admitted on August 6, 2019, had an MDS assessment indicating a substantial maximal need for assistance with self-care. However, the facility's records revealed that Resident R3 did not receive showers on multiple dates in January 2025, specifically on the 1st, 4th, 8th, 11th, and 18th. The Director of Nursing confirmed the facility's failure to provide the required ADL assistance for these residents.
Plan Of Correction
Resident R1 received a shower on 1/26/2025 and R3 received a shower on 1/29/2025. A whole house audit 14 day look back was completed for shower documentation for all residents. The Director of Nursing or designee will educate all nursing staff on proper documentation and complete documentation of bathing. The Director of Nursing or designee will audit all residents bathing documentation daily at morning meetings for 2 weeks, and weekly for 2 weeks, and monthly for 2 months. Audits will be reviewed at the monthly QAPI for further recommendations.
Failure to Report COVID-19 Outbreak
Penalty
Summary
The facility failed to notify the Department of Health about a reportable disease outbreak, specifically a positive COVID-19 outbreak affecting 36 residents. This deficiency was identified during a review of facility documentation and staff interviews conducted on January 28, 2025. The documentation review revealed that the facility did not report the positive COVID-19 cases, which is a requirement for health department reportable diseases. During an interview, the Director of Nursing (DON) admitted to not reporting the positive COVID-19 cases, mistakenly believing that only positive cases among employees needed to be reported. This misunderstanding led to the facility's failure to comply with the notification requirements, thereby compromising the regulatory obligation to report such significant health events to the Department of Health.
Plan Of Correction
1. Residents to equal 36 total have been added to the Department of Health with health reportable events. 2. The NHA or designee will educate the Director of Nursing and Assistant Director of Nursing on notifying the Department of Health with health department reportable diseases. 3. The Director of Nursing or designee will audit all health reportable diseases for notification to the Department of Health daily at morning meetings for 2 weeks, 2 times a week for 2 weeks and then monthly. Results will be reviewed through QAPI for further recommendations.
Resident Elopement Due to Inadequate Supervision and Security Override
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in the resident leaving the facility without permission. The resident, who had a history of attempts to leave the facility unattended and was diagnosed with dementia and a psychotic disorder, was equipped with a security bracelet designed to alert staff if they left a safe area. Despite this precaution, the resident was able to exit the building when a staff member used an identification badge to override the security system and open the door for visitors. On the day of the incident, the resident was observed on camera leaving the third floor and entering the lobby, where they followed visitors towards the exit. The visitors, unaware of the resident's status, did not inform staff that the resident was not with them. A dietary supervisor, believing the resident was part of the visitor group, used their badge to open the door, allowing the resident to exit. The security system alarm was triggered, but the resident had already crossed the threshold and was found outside in the parking lot by staff. Interviews with staff revealed that the security system was functioning correctly, but the use of an identification badge to open the door bypassed the alarm system. The facility's failure to properly identify the resident as a resident and not a visitor, combined with the staff's actions in overriding the security system, led to the resident's unsupervised exit from the facility. The incident was confirmed by the Director of Nursing, who acknowledged the lapse in supervision and identification procedures.
Plan Of Correction
1. The facility increased visual monitoring of Resident R1 and assigned staff to monitor for all residents including R1 usage of elevator during the times of reception employee vacancy. 2. All residents in the facility were reassessed for wandering and elopement risk. Resident care plans were reviewed and updated as needed. Security bracelet list was reviewed. 3. All facility staff are educated by Director of Nursing/Designee on elopement, security bracelet function, behaviors, and how to identify a resident exiting unaccompanied. 4. The Director of Nursing/designee will audit all residents with identified exit seeking behaviors for exit seeking behaviors relating to elevator use daily.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to notify the local State Agency of a reportable event in a timely manner involving a resident who eloped from the facility. The resident, who had been admitted with diagnoses including degeneration of the nervous system due to alcohol, diabetes mellitus, and epilepsy, was found in the parking lot in her wheelchair by a nurse aide. This incident occurred on 11/24/24, but the facility did not report the elopement to the State Agency field office within the required timeframe. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the resident had eloped through the lobby front doors to the parking lot. A review of reports submitted to the local State field office between 11/24/24 and 12/2/24 showed no notification of the elopement event, indicating a failure in the facility's reporting procedures for serious incidents that compromise patient safety.
Plan Of Correction
1. Facility notified the local state agency of the reportable event for Resident R1 on December 5, 2024 after recommendation by local state survey. 2. The Director of Nursing will be educated by Regional Director of Clinical Support on timely event reporting. 3. The Director of Nursing/designee will audit all events for reporting criteria daily for 2 weeks during morning meetings, weekly for 2 weeks, and monthly for 2 months. Audit results will be reviewed at monthly QAPI meetings.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for a resident, identified as Resident R1, who was unable to perform these tasks independently. According to the facility's ADL policy, residents should receive care to maintain or improve their ability to carry out ADLs, including bathing, dressing, grooming, and oral care. Resident R1's MDS assessment indicated a dependency on assistance for self-care activities, with a coding of 1, meaning the helper does all the work. Despite this, the facility's records showed that Resident R1 did not receive showers on three specific dates in October 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on November 6, 2024.
Failure to Notify Medical Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a medical provider of a change in condition for a resident, identified as Closed Resident Record CR1, as required by their policy. The policy mandates prompt notification of the resident's physician and representative in case of significant changes in the resident's condition. However, the review of CR1's clinical progress notes revealed that there was no documentation of a discussion with the physician or other clinical staff regarding CR1's change in status, specifically related to chest pain, nor was there a full set of vitals taken after the onset of this symptom. CR1 had a history of chronic pain and was eager to discharge, as noted in a physician assistant's documentation. On the day of the incident, CR1 requested Oxycodone for pain, which was administered by LPN Employee E1. Despite CR1 expressing chest pain, LPN Employee E1 did not notify a physician or take a full set of vitals, as would be standard procedure for chest pain. Instead, the nurse attempted to manage the situation by talking to CR1 to alleviate anxiety and repositioning him, but did not document these actions thoroughly. Interviews with staff, including LPNs and nurse aides, confirmed that CR1 had complained of chest pain, but the necessary steps to address this change in condition were not taken. The Director of Nursing acknowledged the failure to notify a medical provider as required. The report highlights a deficiency in following the facility's policy for notifying medical providers of significant changes in a resident's condition.
Neglect of Resident's Care Needs During Medical Appointment
Penalty
Summary
The facility failed to protect a resident from physical neglect, as evidenced by the incident involving Resident R1. The resident, who was diagnosed with stroke, Multiple Sclerosis, and unspecified intellectual abilities, required moderate assistance with toileting and transfers. On the day of the incident, Resident R1 was scheduled for an MRI appointment and requested to be changed before leaving the facility. However, the Nurse Aide (NA) Employee E1, who was responsible for escorting the resident, did not attend to this request and took the resident to the appointment without changing him. Upon returning from the appointment, Resident R1 was found heavily soiled with dried bowel movement from his back to his knees. The resident had been sitting in the soiled condition for an extended period, as indicated by the red but unbroken skin. NA Employee E2, who took over the resident's care upon return, confirmed the resident's condition and provided the necessary incontinence care. The resident had informed NA Employee E2 that he had asked NA Employee E1 to take him to the bathroom, but the request was ignored. The facility's documentation and staff interviews corroborated the neglect incident. NA Employee E1 did not provide the required care and subsequently left the facility without addressing the resident's needs. The Nursing Home Administrator and other staff members confirmed the neglect, and the event was substantiated, leading to the termination of NA Employee E1. The facility's failure to protect the resident from neglect was acknowledged by the Nursing Home Administrator.
Medication Misappropriation by RN in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, specifically involving two residents, R2 and R3. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 5/12/24, mandates that residents should be free from such acts. Additionally, the Controlled Substances policy requires reconciliation of medications upon receipt, administration, and disposal, with proper documentation and co-signing by a witness. However, these protocols were not followed, leading to the misappropriation of medications by RN Employee E7. Resident R2, diagnosed with heart failure, diabetes, and COPD, had a physician's order for Oxycodone 30 mg every six hours as needed for pain. Resident R3, with diagnoses of heart failure, diabetes, and cirrhosis, had an order for Oxycodone 10 mg every four hours as needed. It was discovered that RN Employee E7 diverted six doses of oxycodone, as evidenced by discrepancies in medication records and the absence of required co-signatures for destroyed medications. The Director of Nursing confirmed the narcotics could not be accounted for, indicating a failure to ensure residents were free from medication misappropriation.
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to properly store food products in the Main Kitchen, which could lead to foodborne illness. During a review of the facility's policy on Food Receiving and Storage, it was noted that foods should be received and stored in compliance with safe food handling practices, with opened containers being dated and sealed or covered during storage. However, an observation in the Main Kitchen Dry storage area revealed an open box containing a plastic bag of rice and another open box with a plastic bag of pureed bread mix, both of which were not sealed. This was confirmed by the Dietary Director, Employee E13, during an interview.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to uphold the dignity and privacy of its residents in several instances. One resident, identified as R51, was administered medication through a feeding tube without privacy, as a housekeeper was present in the room during the procedure. The Registered Nurse involved admitted to not asking the housekeeper to leave before administering the medication, and the Director of Nursing confirmed this breach of privacy. Another resident, R75, who primarily speaks Spanish and mixes it with Italian, was not provided with adequate communication support. The facility did not have a communication care plan in place to address the resident's language barrier, and staff members struggled to communicate effectively with her. The resident's family members were relied upon for translation, but no formal interpretive services or equipment were available to assist in communication when family members were not present. Additionally, the facility failed to respect the preferred name of a resident, R93. The resident's preferred name was not documented, and staff members did not address her by it. The Social Service Director confirmed that the resident's preference was not recorded, indicating a lack of respect for the resident's personal choice in how she wished to be addressed.
Deficiencies in Resident Transfer and Discharge Documentation
Penalty
Summary
The facility failed to acquire and document a physician's discharge order for one resident, identified as Resident R133, who was scheduled to return to her prior Independent Living Facility. Despite the clinical progress note indicating the discharge plan, there was no documented physician's order authorizing the discharge. This oversight was confirmed by the Director of Nursing during an interview. Additionally, the facility did not ensure that necessary resident information was communicated to the receiving health care provider for five residents who were transferred to a hospital and expected to return. These residents, identified as R28, R43, R64, R75, and R83, had various medical conditions including muscle weakness, quadriplegia, diabetes, high blood pressure, heart failure, anemia, septicemia, and dementia. The facility's failure to provide specific information such as care plan goals, advanced directive information, and instructions for ongoing care was noted in the clinical records and confirmed by the Director of Nursing. The facility's policies on Discharge Summary and Plan, as well as the Transfer Form, require comprehensive documentation and communication of resident information during transfers and discharges. However, the review of resident records revealed a lack of adherence to these policies, resulting in deficiencies in the transfer and discharge processes for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Verona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Longwood At Oakmont | 0.8 mi | ★★★★★ | 12 | 0 |
| Willows Of Presbyterian Senior | 3.1 mi | ★★★★★ | 37 | 0 |
| Southwestern Veterans Center | 3.3 mi | ★★★★★ | 11 | 0 |
| Burgh Care Center | 3.7 mi | ★★★★★ | 47 | 0 |
| Champion City Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 56 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.