Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of University Park during CMS and state inspections, most recent first.
A resident with multiple comorbidities received both scheduled and PRN oxycodone without staff clarifying the orders, leading to increasing lethargy, administration of Narcan for suspected opioid overdose, and a subsequent fall. Nursing and medical staff later acknowledged that the pain management orders should have been clarified, as required by facility policy.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in anticoagulation therapy, dialysis care, oxygen therapy, and pressure injury treatments. Several residents did not have their care plans updated to include necessary treatments, and there were instances where prescribed treatments were not documented as completed.
The facility failed to follow physician orders for weight monitoring and notify providers of significant weight changes for a resident with heart failure. Additionally, the facility did not monitor anticoagulation side effects for three residents, as required by their care plans. An LPN confirmed that the absence of documentation indicated these tasks were not completed. The deficiencies were reported to the facility's administrative staff.
The facility staff failed to provide appropriate respiratory care for several residents, leading to deficiencies. A resident's Bi-PAP mask was not stored in a sanitary manner, and oxygen was not administered according to physician's orders, with incorrect flow rates observed. Another resident did not receive continuous oxygen as ordered, and a third resident's oxygen setting was incorrect. Interviews confirmed that proper storage and administration practices were not followed.
The facility failed to implement a complete pain management program for three residents, as non-pharmacological interventions were not consistently attempted or documented before administering prn pain medications. Despite being cognitively intact, residents did not receive the required interventions, and the facility's records lacked evidence of these efforts. Interviews with staff confirmed the absence of documentation, indicating that interventions were not performed as per the facility's pain management policy.
Facility staff failed to maintain sanitary conditions in the kitchen, with expired food found in the refrigerator and improper sanitizer levels in the sink. A dietary aide was observed handling food without a beard cover, and several food items in nourishment rooms lacked proper labeling. These issues indicate lapses in food safety and personal protective equipment use.
An RN failed to protect resident information privacy by leaving a report sheet with sensitive details visible on a medication cart. The sheet contained room numbers, names, vital signs, and notes, and was left exposed while the RN was in a resident's room, allowing residents and a family member to pass by and potentially view the information. The RN acknowledged the oversight, which violated the facility's policy on safeguarding resident privacy.
The facility failed to document the transfer paperwork sent with two residents to the hospital. In one case, a resident called 911 for chest pain, and in another, a resident was sent to the ER for rapid breathing. In both instances, there was no evidence of required documents being sent, as confirmed by an LPN and the regional clinical coordinator.
The facility failed to provide a bed hold notice for two residents transferred to the hospital. One resident called 911 due to chest pain, and another was sent to the ER for rapid breathing. In both cases, there was no documentation of the bed hold notice being sent with the residents, as confirmed by the regional clinical coordinator.
Facility staff failed to accurately code MDS assessments for a resident, incorrectly documenting insulin administration when the resident was on Trulicity, not insulin. The MDS nurse admitted new staff misunderstood the coding, confusing Trulicity with insulin. The facility's policy stresses the importance of MDS accuracy for quality care and reimbursement. Administrative staff were informed of the findings.
Facility staff failed to accurately complete a PASARR for a resident, marking inconsistencies in the assessment of a serious mental illness. The Director of Social Services confirmed the error, which could hinder the determination of the resident's need for additional services. The issue was reported to the facility's administration.
A facility failed to provide and document scheduled showers for a resident, as evidenced by incomplete ADL records for December and January. The resident was supposed to receive showers twice a week, but several instances lacked documentation. A CNA indicated that undocumented showers imply they were not given, and the nurse should be informed. The facility could not provide a policy on ADL care for showers/bathing.
A resident with two stage three pressure injuries did not receive documented treatments as per physician orders. The treatment administration records showed multiple blanks for prescribed wound care, and nurse's notes lacked explanations for these omissions. Interviews with the DON and an LPN confirmed that undocumented treatments were likely not performed.
The facility failed to monitor fluid restrictions for three residents with conditions like CHF, DM, and ESRD. Fluid intake exceeded prescribed limits, and documentation was inconsistent or missing. Staff interviews revealed a lack of adherence to the facility's fluid restriction policy, leading to deficiencies in resident care.
A facility failed to monitor the bruit and thrill of a resident's dialysis access site, as required by their care plan and physician's orders. Despite the resident's ESRD and diabetes, there was no documentation of these assessments in the MAR and TAR for March and April. Interviews with the resident and staff confirmed the lack of monitoring, and the facility's hemodialysis policy was not followed.
A nurse was observed breaching infection control practices by handling medications with bare hands before administering them to a resident. The facility's policy requires that medications in contact with bare hands be disposed of and replaced. The incident was reported to the administrator, DON, and regional clinical coordinator.
A resident was not provided education or offered the most recent influenza vaccination due to a lapse in the facility's immunization program. The responsibility for offering the vaccine was assigned to an assistant director of nursing who no longer works at the facility, and the Director of Nursing could not explain the oversight. Facility policy required obtaining an order and providing education for eligible residents, but this was not followed.
A resident was not educated about or offered the most recent COVID-19 vaccine, as required by the facility's immunization program. The DON acknowledged that the assistant DON, who is no longer with the facility, was responsible for this task but failed to ensure it was completed.
The facility failed to conduct annual performance reviews for six CNAs, as required by policy. The DON, who assumed the role in September 2023, could not provide the evaluations for the CNAs with anniversary years from June 2022 to March 2024. Despite being informed of the deficiency, no further information was provided by the facility's administrative staff.
The facility staff failed to include required daily census information in 25 out of 30 staff postings reviewed. The DON acknowledged the omission and stated that the scheduler, responsible for posting, was absent, and she took over the task. A policy on daily staff posting was requested but not provided. The findings were communicated to the facility's administration, but no further information was given.
Facility staff failed to maintain the trash compactor in a sanitary manner by not keeping its door closed, exposing debris inside. The dietary manager stated that all staff were responsible for ensuring the door was closed, with the dietary department held accountable. The open door was noted to potentially allow rodents to enter.
The facility failed to ensure that five out of six CNAs met the required training standards, including a minimum of 12 hours of annual training and specific training in dementia care and abuse prevention. The DON acknowledged the lack of documentation for the required training, noting that the time frames were before her tenure.
Failure to Clarify Oxycodone Orders Resulting in Opioid Overdose and Fall
Penalty
Summary
Facility staff failed to adhere to professional standards by not clarifying overlapping and potentially conflicting oxycodone orders for a resident with complex medical conditions, including end stage renal disease, dialysis, diabetes mellitus, and congestive heart failure. The resident was admitted with significant functional dependencies and a history of pain related to a left lower extremity fracture and a large unstageable sacral wound. Physician orders included both an as-needed (PRN) oxycodone-acetaminophen and a scheduled extended-release oxycodone, but staff did not clarify the appropriateness or parameters for concurrent administration of these medications. On multiple occasions, nursing staff administered the prescribed pain medications without seeking clarification, despite the resident exhibiting increasing lethargy and changes in responsiveness. Documentation shows that the resident became progressively more lethargic after the initiation of the scheduled extended-release oxycodone, with both staff and the resident's family expressing concern. The situation escalated to the point where the resident required administration of Narcan due to suspected opioid overdose, after which the resident became agitated and suffered a fall from bed. Interviews with nursing staff and the physician confirmed that the orders should have been clarified, especially given the resident's change in condition and the risk of opioid toxicity in a patient with renal impairment. Facility policy required nurses to seek clarification for incomplete or unclear orders, but this was not done. The resident was ultimately transferred to the hospital, where he was diagnosed with pneumonia, ESRD, and opiate overdose.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility staff failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. For Resident #17, the care plan did not include anticoagulation therapy despite a physician's order for Eliquis, an anticoagulant. The LPN acknowledged that monitoring for bruising and bleeding should have been included in the care plan. Similarly, Resident #18's care plan lacked documentation for anticoagulation therapy, even though there was a physician's order for Apixaban. The LPN confirmed that such therapy should be part of the care plan, including monitoring for potential side effects. Resident #35's care plan was incomplete regarding dialysis care and oxygen therapy. Although the care plan mentioned the risk of complications related to dialysis, it did not include monitoring for bruit/thrill of the fistula, which is essential for dialysis patients. Additionally, the care plan for oxygen therapy was not implemented as prescribed. The LPN admitted that the care plan was not followed, as the oxygen was set at a different rate than ordered. Resident #135 also had a care plan deficiency, as it did not include anticoagulation therapy despite a physician's order for Apixaban. For Resident #189, the facility staff failed to implement the comprehensive care plan for pressure injury treatments. The treatment administration record showed several instances where the prescribed wound care treatments were not documented as completed, and there was no evidence in the nurse's notes explaining the omissions. This lack of documentation and implementation of the care plan indicates a failure to provide the necessary care for the resident's pressure injuries.
Failure to Follow Physician Orders and Monitor Anticoagulation Side Effects
Penalty
Summary
The facility staff failed to provide care and services in accordance with professional standards of practice and the comprehensive care plan for four residents. For one resident with heart failure, the staff did not follow physician orders to obtain weights on specified days and failed to notify the provider of a significant weight gain. The medication administration record (MAR) lacked documentation of weights on two required days, and there was no evidence of provider notification despite a weight gain exceeding the threshold outlined in the physician's order. An LPN confirmed that the absence of documentation indicated the task was not completed. For three other residents, the facility failed to monitor anticoagulation side effects as required. These residents were on anticoagulant medications, but the MAR and treatment administration record (TAR) showed no evidence of monitoring for signs of bruising and bleeding, which are critical side effects of anticoagulation therapy. An LPN stated that monitoring should be documented on the MAR/TAR, and the lack of documentation suggested that monitoring was not performed. The facility's policy required monitoring for signs and symptoms of bleeding and immediate notification of the physician if such signs were noted. The deficiencies were brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional clinical coordinator. Despite the facility's policies and procedures, the staff's failure to document and carry out physician orders and monitor critical medication side effects resulted in these deficiencies. No further information or corrective actions were provided before the surveyors exited the facility.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for several residents, leading to deficiencies in the care provided. For Resident R32, the staff did not store the Bi-PAP mask in a sanitary manner, as it was repeatedly observed uncovered on the bedside table. Additionally, the staff did not administer oxygen according to the physician's orders, as the resident was receiving oxygen at a lower flow rate than prescribed. Despite the physician's order for 6 liters per minute, the resident was observed receiving only 4 liters per minute. Resident R38 also experienced a deficiency in care, as the staff failed to administer oxygen continuously as ordered by the physician. Observations revealed that the oxygen tubing and nasal cannula were on the floor, and the resident was not receiving oxygen for approximately 41 minutes. Although the LPN stated that the resident refused oxygen, it was noted that the resident should have been offered oxygen earlier. For Resident R35, the staff did not adhere to the physician's orders for continuous oxygen at 2 liters per minute. Observations showed that the oxygen setting was at 3 liters per minute instead. Similarly, Resident R2's Bi-PAP mask was not stored in a sanitary manner, as it was found hanging over the machine without being covered. Interviews with staff confirmed that the masks should be stored in a plastic bag when not in use, but this practice was not followed.
Failure in Pain Management Program Implementation
Penalty
Summary
The facility staff failed to implement a complete pain management program for three residents, resulting in deficiencies in the administration of pain medications. For one resident, the staff did not attempt non-pharmacological interventions before administering prn pain medication, Oxycodone 5mg, on multiple occasions. The resident was cognitively intact and reported occasional pain, but the facility's electronic medication administration record (eMAR) and progress notes lacked documentation of non-pharmacological interventions. Interviews with the resident and a licensed practical nurse (LPN) confirmed that non-pharmacological interventions were not consistently attempted or documented. Another resident also did not receive non-pharmacological interventions before being administered prn pain medications, including Oxycodone and Acetaminophen. The resident was cognitively intact and experienced occasional pain, but the eMAR and progress notes showed no evidence of non-pharmacological interventions. An LPN acknowledged the lack of documentation and stated that non-pharmacological interventions should have been attempted and documented before administering medication. A third resident, who had a comprehensive care plan for pain management due to conditions like breast cancer with bone metastasis and diabetes mellitus, also did not receive documented non-pharmacological interventions. The care plan included various non-pharmacological interventions, but the medication administration record for March and April was blank in the section for documenting these interventions. An LPN confirmed that the absence of documentation indicated that the interventions were not performed. The facility's pain management policy required individualized interventions, including both pharmacological and non-pharmacological methods, but these were not consistently implemented or documented for the residents involved.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility staff failed to store, prepare, and serve food in a sanitary manner, as observed during an inspection of the kitchen. Five bags of chopped cabbage with expired use-by dates were found on the top shelf inside the walk-in refrigerator, which were immediately removed by the dietary manager. Additionally, the sanitizer level in the three-compartment sink was found to be at 50ppm, which was below the required 200ppm for sanitizing kitchen items, indicating improper sanitization practices. Further observations revealed a dietary aide working on the tray line without a beard cover, despite handling resident trays with food and beverages. The dietary aide admitted to not knowing where the beard guards were kept, but later located them next to the kitchen door. This lack of proper personal protective equipment use could potentially lead to contamination of food served to residents. In the nourishment rooms, several food items were found without labels indicating the resident's name or room number, contrary to the facility's policy. These items included frozen dinners, beverages, and various other food products. The dietary manager stated that nursing staff should label food brought in from outside, and dietary aides are responsible for checking the refrigerators and freezers when stocking them. However, the lack of labeling and oversight suggests a failure in following established procedures for food safety and storage.
Failure to Protect Resident Information Privacy
Penalty
Summary
The facility staff failed to ensure the privacy of resident information on one of six medication carts. An observation was made of an RN administering medications in the 200 hallway, during which the RN left a report sheet on top of the cart. This report sheet contained sensitive resident information, including room numbers, names, vital signs, and notes, and was left visible to residents and family members passing by. During the time the RN was in a resident's room, five residents and one family member walked past the medication cart, potentially exposing the private information. When interviewed, the RN acknowledged the oversight and stated that the document should have been turned over to protect resident privacy. The facility's policy on Guest/Resident Rights emphasizes safeguarding the privacy of residents' protected health information from improper use and disclosure.
Failure to Document Transfer Paperwork for Hospitalized Residents
Penalty
Summary
The facility staff failed to provide evidence that the required documents were sent to the hospital upon the transfer of two residents, leading to a deficiency. For the first resident, the nurse's note indicated that the resident called 911 due to chest pain and was transported to the hospital. However, there was no documentation in the clinical record of what documents were sent with the resident. An LPN confirmed that necessary documents such as the face sheet, medication list, diagnoses list, bed hold policy, and care plan should be sent and documented in a nurse's note, but this was not done. The regional clinical coordinator also confirmed the lack of documentation and stated that even in resident-initiated transfers, the paperwork should be sent and documented. For the second resident, the nurse's note documented that the resident was sent to the emergency room due to rapid breathing and non-responsiveness, as assessed by a nurse practitioner. The clinical record again failed to show evidence of what documents were sent with the resident to the hospital. The regional clinical coordinator presented a transfer form but confirmed it did not document the paperwork sent with the resident. The administrator, director of nursing, and regional clinical coordinator were made aware of these concerns, but no further information was obtained before the survey exit.
Failure to Provide Bed Hold Notice for Hospital Transfers
Penalty
Summary
The facility staff failed to provide a bed hold notice upon transfer for two residents, leading to a deficiency. For the first resident, the transfer to the hospital occurred after the resident called 911 due to chest pain, without notifying the staff of any discomfort. The nurse's note documented the transfer, but there was no evidence of what documents were sent with the resident, including the bed hold notice. An LPN stated that typically a face sheet, medication list, diagnoses list, bed hold policy, and care plan are sent with the resident, and this should be documented in a nurse's note. However, the regional clinical coordinator confirmed there was no documentation of the bed hold notice being sent. For the second resident, the transfer was initiated by a nurse practitioner after the resident exhibited rapid breathing and was unresponsive. The nurse called 911, and the resident was sent to the hospital. Again, there was no evidence in the clinical record of what documents were sent with the resident, including the bed hold notice. The regional clinical coordinator confirmed that the SNF/NF Transfer to hospital form did not document the paperwork sent with the resident, and there was no evidence of a bed hold notice. The administrator, director of nursing, and regional clinical coordinator were made aware of these concerns.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility staff failed to ensure accurate MDS assessments for a resident, specifically regarding the administration of insulin. The MDS assessments for the resident were incorrectly coded as the resident receiving insulin injections, despite the resident being on Trulicity, which is not an insulin. The assessments in question were the quarterly assessments from March and September 2023, and the annual assessment from June 2023. A review of the clinical record confirmed that there were no active insulin orders for the resident during the time of these assessments. The MDS nurse, RN #2, acknowledged that the new MDS staff misunderstood the coding for insulin injections, likely confusing Trulicity with insulin due to its use in diabetes management. The facility's policy on the accuracy of MDS assessments emphasizes the importance of verifying the accuracy of the MDS to ensure quality care and proper reimbursement. The facility's administrative staff, including the Administrator, Director of Nursing, and Regional Clinical Coordinator, were informed of these findings, but no further information was provided by the end of the survey.
Inaccurate PASARR Completion for a Resident
Penalty
Summary
The facility staff failed to accurately complete the PASARR (Pre Admission Screening and Resident Review) for one resident, which is essential to determine if the resident has a mental condition requiring additional services. The clinical record for the resident included a PASARR form dated 7/20/22, where the question regarding the presence of a serious mental illness was marked 'Yes'. However, the subsequent questions, which are prerequisites for confirming a serious mental illness, were all marked 'No'. This inconsistency indicates that the PASARR was not completed in accordance with the instructions, which require all subsequent items to be marked 'Yes' to confirm a serious mental illness. During an interview, the Director of Social Services acknowledged that the PASARR was not completed correctly, which could prevent the facility from determining if the resident needed additional services. The facility's policy requires a new PASARR screening if an incorrect one is received upon admission. The deficiency was brought to the attention of the Administrator, Director of Nursing, and Regional Clinical Coordinator, but no further information was provided by the end of the survey.
Failure to Document and Provide Scheduled Showers
Penalty
Summary
The facility staff failed to provide adequate ADL care for a dependent resident, identified as Resident #136, who was part of the survey sample. The resident was admitted and discharged within a specific timeframe, and the review of their ADL records for December 2023 and January 2024 showed inconsistencies in the documentation of showers. In December, out of seven opportunities for a shower, only four were documented, with one instance marked as the resident being unavailable and two instances lacking documentation. Similarly, in January, out of seven opportunities, only four showers were documented, with three instances lacking documentation. The facility's ADL logs did not account for any bathing outside of scheduled shower days, making it unclear if the resident received any additional bathing. During an interview, a CNA stated that showers should be documented on the ADL log, and if not, it is assumed the resident did not receive a shower, and the nurse should be notified. The facility was unable to provide a policy regarding ADL care for showers/bathing when requested.
Failure to Document and Administer Pressure Ulcer Treatments
Penalty
Summary
The facility staff failed to provide adequate care and services for the treatment of pressure injuries for one resident, identified as Resident #189. The resident, who was not cognitively impaired, had two stage three pressure injuries as noted in the most recent MDS assessment. The facility did not document the completion of prescribed treatments for these injuries on multiple occasions, as evidenced by blanks in the treatment administration records (TAR) for both the sacral wound and the left heel wound. The nurse's notes did not provide any explanation for the missing documentation. For the sacral wound, physician orders required cleansing with normal saline and application of Hydrofera Blue, secured with an island border dressing every evening. However, the TAR for November 2022 and January 2023 showed blanks on specific dates where the treatment was not documented as completed. Similarly, for the left heel wound, orders required cleansing with normal saline and application of Medihoney with calcium alginate, but the TAR for November 2023, December 2023, and January 2023 also showed blanks on several dates. Additionally, a new order for the left heel wound in January 2023 was not documented as completed on two occasions. The facility's policy on skin management emphasizes the identification, evaluation, and provision of appropriate treatment for residents with wounds or at risk for skin compromise. Interviews with the director of nursing and an LPN confirmed that a blank on the TAR generally indicates that the treatment was not documented, and if not documented, it was likely not done. Despite being made aware of these concerns, no further information was obtained before the survey exit.
Failure to Monitor Fluid Restrictions for Residents
Penalty
Summary
The facility failed to adequately monitor fluid restrictions and intake for three residents, leading to deficiencies in their care. Resident #17, who was diagnosed with congestive heart failure (CHF) and diabetes mellitus (DM), had a fluid restriction order of 1800cc per day. However, the Medication Administration Record (MAR) for March 2024 did not document this restriction, and in April 2024, the recorded fluid intake exceeded the prescribed limits on several occasions. Interviews with staff revealed a lack of consistent documentation and adherence to the fluid restriction policy. Resident #18, with diagnoses including CHF, acute respiratory failure, and chronic kidney disease, had a fluid restriction order of 2000cc. The MAR for March and April 2024 showed missing documentation on multiple shifts, indicating a failure to consistently monitor and record fluid intake. Staff interviews confirmed that the fluid restriction should be documented on the MAR, but this was not consistently done, leading to gaps in monitoring. Resident #35, diagnosed with end-stage renal disease, COPD, CHF, and DM, had a fluid restriction order of 1500cc. The April 2024 MAR did not reflect this restriction, and the resident was unaware of their fluid restriction. Interviews with staff highlighted a lack of communication and documentation regarding fluid restrictions. The facility's policy required coordination between dietary and nursing staff to manage fluid restrictions, but this was not effectively implemented, resulting in deficiencies in care for these residents.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease (ESRD) and diabetes, specifically by not monitoring the bruit and thrill of the resident's left arm fistula. The comprehensive care plan for the resident, dated March 20, 2024, included interventions to observe for signs and symptoms of complications related to dialysis, such as bleeding, bruising, and infection. Physician's orders dated April 23, 2024, specified that the resident was to undergo hemodialysis on Tuesdays, Thursdays, and Saturdays, with instructions to observe the dialysis site for various complications every shift. However, a review of the resident's medical records, including the medication administration record (MAR) and treatment administration record (TAR) for March and April 2024, revealed no evidence of assessment for bruit and thrill. Interviews conducted with the resident and facility staff confirmed the lack of monitoring. The resident stated that they did not believe the bruit and thrill were being monitored. The director of nursing acknowledged the absence of documentation for the bruit and thrill. An LPN confirmed that the documentation should have been recorded on the TAR and that its absence indicated the assessment was not performed. The facility's hemodialysis policy required daily evaluation of the dialysis access site for complications, including the presence of a thrill and bruit, and to notify the physician if these were absent. Despite these requirements, the facility did not provide evidence of compliance with these monitoring protocols for the resident in question.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility staff failed to maintain proper infection control practices during a medication administration observation. On April 22, 2024, at 11:32 a.m., a registered nurse (RN) was observed administering medications in the 200 hallway. The RN was seen popping two medications out of a medication bubble pack and dropping the pills into her hand before placing them into a medication cup and administering them to a resident. During an interview conducted at 11:55 a.m. on the same day, the RN acknowledged the observation and admitted that nurses should not touch a resident's medications with their hands due to sanitary reasons and the risk of germs. The facility's medication administration policy states that if medications come into contact with the bare hands of the nurse or with the medication cart, the medication should be disposed of according to policy and new medications obtained. The administrator, director of nursing, and regional clinical coordinator were informed of the concern on April 23, 2024, at 4:50 p.m. No further information was provided before the exit.
Failure to Implement Complete Immunization Program
Penalty
Summary
The facility staff failed to implement a complete immunization program for a resident, identified as Resident #5, who was admitted to the facility on an unspecified date. The deficiency was identified through staff interviews, facility document reviews, and clinical record reviews. Specifically, the staff did not provide education or offer the most recent influenza vaccination to Resident #5. The Director of Nursing, during an interview, stated that the responsibility for ensuring all residents were offered the influenza vaccine fell to the assistant director of nursing, who no longer works at the facility. The Director of Nursing acknowledged that residents should have been given a form detailing the risks and benefits of the vaccine and an opportunity to accept or decline it. However, there was no explanation provided for why the responsible staff member did not fulfill their duties. The facility's policy on immunizations indicated that beginning in October, the standing protocol was to administer the vaccine, obtain an order if the resident was eligible, and provide education, but this was not followed for Resident #5.
Failure to Implement Complete COVID-19 Immunization Program
Penalty
Summary
The facility staff failed to implement a complete immunization program for one of the residents, identified as Resident #5, who was reviewed for immunizations. Resident #5 was admitted to the facility, but there was no evidence in her clinical record that she was educated about or offered the most recent COVID-19 vaccine. This oversight was identified during a review of the resident's clinical records. The director of nursing, identified as ASM #2, acknowledged during an interview that the assistant director of nursing, who is no longer employed at the facility, was responsible for ensuring all residents were offered the most recent COVID-19 vaccine. However, the director could not explain why the responsible staff member did not fulfill their duties. The facility's policy required that residents be educated about the vaccine and provided with a consent form to accept or decline the vaccine, but this process was not followed for Resident #5.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility staff failed to conduct annual performance reviews for six Certified Nursing Assistants (CNAs) as required by their policy. The CNAs in question had anniversary years ranging from June 2022 to March 2024. During a survey conducted on April 23 and 24, 2024, the Director of Nursing (DON) was unable to provide the requested evaluations, stating that the time frames were prior to her assuming the role in September 2023. The facility's policy mandates annual competency evaluations for all certified nurse aides, with training scheduled based on identified weaknesses. Despite being informed of the deficiency, the facility's administrative staff, including the Administrator, DON, and Regional Clinical Coordinator, did not provide further information by the end of the survey.
Failure to Include Daily Census Information in Staff Postings
Penalty
Summary
The facility staff failed to ensure that the required daily census information was included in 25 out of 30 staff postings reviewed. This deficiency was identified during a review of daily staff postings from March 23, 2024, through April 21, 2024. The Director of Nursing (DON) acknowledged that the census information should be documented on the postings and mentioned that the scheduler, who usually posts the daily staffing, was absent on April 22 and 23, 2024. In the scheduler's absence, the DON was responsible for posting the information. However, a policy regarding the daily staff posting was requested but not provided. The findings were communicated to the Administrator, the DON, and the Regional Clinical Coordinator, but no further information was provided by the end of the survey.
Failure to Maintain Trash Compactor Sanitation
Penalty
Summary
The facility staff failed to maintain the trash compactor in a sanitary manner by not keeping its door closed. On April 22, 2024, at approximately 11:40 a.m., an observation revealed that the door to the facility's trash compactor was open, exposing the debris inside. During an interview at 2:06 p.m., the dietary manager, identified as OSM #4, stated that it was the responsibility of all facility staff to ensure the door was closed, but the dietary department would be held accountable. The dietary manager acknowledged the importance of keeping the door closed to prevent rodents from entering and staying away from the building. No further information was provided before the exit.
Deficiency in CNA Training Requirements
Penalty
Summary
The facility staff failed to ensure that five out of six reviewed Certified Nursing Assistant (CNA) records met the required training standards. Specifically, the CNAs did not complete the mandatory minimum of 12 hours of annual training, and some were missing specific training in dementia care and abuse prevention. The review of CNA records revealed that CNA #3 was missing dementia care training, CNA #4 and CNA #5 did not meet the 12-hour annual training requirement, CNA #6 lacked both dementia care training and the required annual training hours, and CNA #7 was missing abuse training and did not meet the annual training hours. During an interview, the Director of Nursing (DON) acknowledged the lack of documentation for the required training and noted that the time frames in question were before her tenure, which began in September 2023. The facility's policy on staff development mandates that nurse aides receive no less than 12 hours of in-service education per year, including training on abuse prohibition and dementia care. Despite being informed of these findings, the facility's administrative staff, including the Administrator, DON, and Regional Clinical Coordinator, did not provide any additional information by the end of the survey.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedarfield Pinnacle Living | 0.7 mi | — | 0 | 0 |
| August Healthcare At Richmond | 2 mi | ★★★★★ | 6 | 0 |
| Westport Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 16 | 0 |
| Shalom Gardens Health & Rehabilitation | 2.9 mi | ★★★★★ | 8 | 2 |
| Lakewood Manor | 3.6 mi | ★★★★★ | 0 | 0 |
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