Pennsylvania Department of Health
UPMC MAGEE-WOMENS HOSPITAL TRANSITIONAL CARE UNIT
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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UPMC MAGEE-WOMENS HOSPITAL TRANSITIONAL CARE UNIT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and abbreviated survey completed on November 25,2025, it was determined that UPMC Magee-Women's Hospital TCU was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.80 Infection control
§483.80(d)(3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses.
(v) The resident or resident representative, has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision; and
(vi) The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident, or
(C) If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
(vii) The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Observations:

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for five out of five residents (Resident R6, R9, R27, R28, and R36).

Findings include:

Review of facility policy "Infection Control - Immunizations" dated 9/25/25, indicated Pneumococcal, Covid, and Influenza immunizations will be offered to residents. Other immunizations will be offered as indicated. The purpose is to prevent transmission of agents. Upon admission, establish immunization status with resident or resident representative.
Review of Resident R6's clinical record indicated the resident was admitted to the facility on 10/15/25.

Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/22/25, indicated diagnoses of hypertension, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and anemia (too little iron in the body causing fatigue). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID-19 vaccine was coded a "0"- resident not up to date.
Review of clinical records indicated that Resident R6's last received a COVID-19 vaccination on 2/9/22.

During a review of Resident R6's clinical record on 11/24/25, at 12:35 p.m. failed to include documentation that a Covid-19 booster vaccine was offered.
Review of Resident R9's clinical record indicated the resident was admitted to the facility on 11/2/25.

Review of Resident R9's MDS dated 11/9/25, indicated diagnoses of hypertension, diabetes, and deep vein thrombosis (blood clot forms in a deep vein).
Review of clinical records indicated that Resident R9's last received a COVID-19 vaccination on 12/2/21.

During a review of Resident R9's clinical record on 11/24/25, at 12:37 p.m. failed to include documentation that a Covid-19 booster vaccine was offered.
Review of Resident R27's clinical record indicated the resident was admitted to the facility on 11/7/25.

Review of Resident R27's MDS's dated 11/14/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), edema, and osteoporosis (condition when the bones become brittle and fragile). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID-19 vaccine was coded a "0"- resident not up to date.

Review of clinical records indicated that Resident R27's last received a COVID-19 vaccination on 4/14/21.

During a review of Resident R27's clinical record on 11/24/25, at 12:39 p.m. failed to include documentation that a Covid-19 booster vaccine was offered.
Review of Resident R28's clinical record indicated the resident was admitted to the facility on 11/12/25.

Review of Resident R28's MDS's dated 11/19/25, indicated diagnoses of osteoporosis, chronic pain, and epilepsy (disorder of the brain characterized by repeated seizures).
Review of clinical records indicated that Resident R28's last received a COVID-19 vaccination on 11/11/21.

During a review of Resident R28's clinical record on 11/24/25, at 12:43 p.m. failed to include documentation that a Covid-19 booster vaccine was offered.
Review of Resident R36's clinical record indicated the resident was admitted to the facility on 11/12/25.

Review of Resident R36's MDS's dated 11/24/25, indicated diagnoses of high blood pressure, cellulitis (bacterial skin infection), and gastroesophageal reflux disease (GERD- chronic digestive disorder where stomach acid flows back into throat). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID-19 vaccine was coded a "0"- resident not up to date.

Review of clinical records indicated that Resident R36's last received a COVID-19 vaccination on 7/7/22.

During a review of Resident R36's clinical record on 11/24/25, at 12:47 p.m. failed to include documentation that a Covid-19 booster vaccine was offered.

During an interview on 11/24/25, at 1:17 p.m. Registered Nurse Assessment Coordinator Employee E1 stated the facility does not offer Covid vaccines to residents and confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for five out of five residents (Resident R6, R9, R27, R28, and R36).

28 Pa. Code 211.5(f)(i)-(xi) Clinical records

Plan of Correction - To be completed: 01/12/2026

Residents R6, R9, R27, R28 and R36 were offered the latest covid vaccine and declined receiving it.

At the time of the finding all residents were assessed and offered the latest covid vaccine.

All RNs, LPNs and Nurse Practitioners will be educated by the Administrator and/or designee to offer the covid vaccine upon admission for all residents that it is not medically contraindicated to administer.

NHA or designee will audit/observe 4 admissions per week to ensure the covid vaccine is being offered on admission for all residents in which it is medically safe to administer. Audits will be conducted weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved.

The results will be reviewed at the QAPI Committee meetings.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon discharge for two out of three closed resident records (Residents CR25 and Resident CR26).

Findings include:

The facility "Admission, transfer, discharge policy last reviewed on 9/25/25, indicated that the discharge of a resident from the facility is conducted in an organized manner, focusing on continuity of care.

Review of Resident CR25's admission record indicated he was admitted on 9/9/25.

Review of Resident CR25's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 9/16/25, indicated that he had diagnoses which included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and coronary artery disease (narrowing/blockage of vessels that carry blood and oxygen to the heart).

Review of Resident CR25's discharge plan documentation indicated he was discharged home with his wife and home health services.

Review of Resident CR26's admission record indicated he was admitted on 1/27/25.

Review of Resident CR26's MDS assessment dated 2/3/25, indicated he had diagnoses that included left clavicle fracture, hypertension and osteoporosis.

Review of Resident CR26's discharge records indicated he was discharged to a nursing facility on 2/24/25.

Review of facility notifications to the State Ombudsman office did not include notifications of Closed Resident Record CR25 and CR26 discharges.

During an interview on 11/25/25, at 9:30 am. the Nursing Home Administrator (NHA) confirmed that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon discharge for Closed Resident Records R25 and R26 as required.

28 Pa. Code: 201.29 (ac.3) (2) Resident rights.

Plan of Correction - To be completed: 01/12/2026

All November discharges were reviewed and sent to the Ombudsman's Office on 12/4/2025.

NHA/Designee will educate DON, NHA and Discharge planner on the need to send notice of all discharges to the office of LTC Ombudsman on a monthly basis.

NHA/designee will audit submissions each month for the next 4 months or until substantial compliance is achieved.

Data will be shared at the quarterly QA meeting.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Resident R30).

Findings include:

Review of facility policy "Tube Feeding via Enteral Feeding Pump" last reviewed 9/25/25, indicated to deliver a liquid feeding formula directly to the stomach. Enteral feeding and tubing are changed every 24 hours or when a new bottle is hung. Label feeding bag/bottle with date and time hung.

Review of the clinical record indicated Resident R30 was admitted to the facility on 11/7/25, with diagnosis of breast cancer, hypotension (low blood pressure) and abdominal discomfort.

Review of a nutrition communication note dated 11/21/25, indicated Resident R30's recommended tube feeding formula is Kate Farm 1.5 calorie with goal rate of 50 milliliters (ml) per hour with water flush of 150 ml every four hours.

Review of Resident R30's nursing notes dated 11/24/25, indicated tube feeding method continuous with rate of 50ml/hour tolerating without feeling of fullness.

During an observation on 11/24/25, at 9:11 a.m. Resident R30's enteral feeding formula and water bag were noted in room infusing via pump. The formula and water bag failed to be labeled with a date or time hung.

During an interview on 11/24/25, at 9:15 a.m. Registered Nurse Employee E2 stated "I know she just hung it last night".

During an interview on 11/24/25, at 9:15 a.m. RN Employee E2 confirmed that the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications for one of three residents (Resident R30).

28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/12/2026

Resident R30's enteral tube feeds have been labeled and dated upon placement.

On the day of the finding, residents receiving enteral tube feeds were assessed to ensure all formula and water bags were labeled with date and time hung.

All RNs and LPNs will be educated by the Director of Nursing or designee that when a formula bag is hung, it must be labeled appropriately with a date and time of when it was initially hung.

The Director of Nursing and/or designee will audit all residents on enteral feeds, to ensure that the formula is labeled appropriately with a date and time. Audits will be completed weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved.

Results will be reviewed at the Quarterly QA meeting.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted catheter (a thin plastic tube inserted into a vein using a needle) in accordance with professional standards of practice for one of two residents (Resident R33).

Findings include:

Review of the facility policy "Intravenous (IV) Therapy: Peripheral, Including Midlines" last reviewed 9/25/25, indicates to maintain venous access, administer continuous/intermittent intravenous fluids, nutrition, medications, and blood products over a specific time frame. All registered Nurses and Licensed Practical Nurses that complete the IV therapy program are responsible for including but not inclusive to:
. IV site inspection a minimum of every shift.
. Maintain a clean, dry and intact dressing over insertion site.
. Document date and time.

Review of Resident R33's clinical record indicates an admission date of 11/12/25, with the diagnosis of hernia (when an organ or fatty tissue squeezes through a weak spot in muscle or connective tissue) repair, muscular deconditioning (wasting or thinning of muscle mass) and obesity.

Review of Resident R33's clinical documentation indicated a size 22-gauge peripheral catheter was inserted to the left wrist on 11/23/25.

During an observation on 11/24/25, at 9:32 a.m. Resident R33 was sitting in her wheelchair, a peripheral IV access site was noted to her left wrist. The IV site was noted not to have been labeled with a date or time of insertion.

During an interview on 11/24/25, at 9:34 a.m. Licensed Practical Nurse Employee E3 confirmed the IV access site dressing did not contain a date or time of insertion and that the facility failed to provide adequate treatment and care for a peripherally inserted catheter in accordance with professional standards of practice for one of two residents (Resident R33).

28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.
28 Pa. Code: 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 01/12/2026

R33 has been discharged.

On the day of the finding, residents with IVs were assessed to ensure dressing sites were labeled with a date and time, and that all dressings were intact without any signs or symptoms of complications.

All RNs and LPNs will be educated by the Director of Nursing or designee that when an IV is in place, the dressing must be labeled appropriately with a date and time, and that all dressings should be inspected at least once a shift to ensure the dressing is intact and without any signs or symptoms of complications.

The Director of Nursing and/or designee will audit all residents with an IV in place, to ensure that the dressing is labeled appropriately with a date and time, and that all dressings are being inspected at least once a shift to ensure the dressing is intact and without any signs or symptoms of complications. Audits will be completed weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved.

Results will be reviewed at the Quarterly QA meeting.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on a review of policy, observation and staff interview, it was determined that the facility failed to maintain the cleanliness and sanitation of equipment to prevent the potential for cross-contamination or foodborne illness in the Transition Care Unit (TCU) Dining Room (3rd floor, 3100 unit).

Findings include:

Review of facility policy "SRC-Food and Nutrition - Sanitation-AB" dated 9/30/25, indicated all employees are responsible for keeping equipment and the department clean. All kitchen equipment will be cleaned and sanitized following each use.

During an observation on 11/24/25, at 10:45 a.m., of the dining room on the TCU, which included the Resident Pantry area, revealed the microwave oven's (kitchen appliance used to reheat foods) interior cooking surfaces were covered with dried food particles and splatters of dried food debris.

During an interview on 11/24/25, at 11:02 a.m., the Nursing Home Administrator (NHA) confirmed the unit's microwave oven needed cleaned and sanitized and that the facility failed to maintain the cleanliness and sanitation of equipment to prevent the potential for cross-contamination or foodborne illness in the Transition Care Unit (TCU) Dining Room (3rd floor, 3100 unit).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.

Plan of Correction - To be completed: 01/12/2026

On the day of the finding the microwave was cleaned and sanitized according to policy.

All housekeeping staff will be educated on the importance of cleaning and sanitizing the microwave Qday and as necessary when visibly soiled. A sign off sheet will be provided to ensure compliance and accountability.

The Nursing Home Administrator and/or designee will audit the sanitation log to ensure the microwave has been cleaned at least daily. Audits will be completed weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved.

Results will be reviewed at the Quarterly QA meeting.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on facility policy, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure that Infection Control meetings had all the required nine multidisciplinary members present at the Infection Control meetings for four of four quarters (Quarters One, Two, Three, and Four).

Findings include:

Review of facility "Infection Prevention and Control Program" policy dated 9/25/25, indicated to provide a program incorporating surveillance, prevention, and control of infection for the health and safety of the population we serve in our geographical location. Meets are at least quarterly and includes a multidisciplinary team of representatives.

During an interview on 11/24/25, the Nursing Home Administrator stated that they have quarterly Infection Control Meetings.

Review of the facility's First Quarterly Infection Control Committee Meeting attendance log form dated 1/21/25, failed to reveal that a Lab representative was in attendance.

Review of the facility's Second Quarterly Infection Control Committee Meeting attendance log form dated 4/15/25, failed to reveal that a Lab representative was in attendance.

Review of the facility's Third Quarterly Infection Control Committee Meeting attendance log form dated 7/22/25, failed to reveal that a Lab representative was in attendance.

Review of the facility's Fourth Quarterly Infection Control Committee Meeting attendance log form dated 10/21/25, failed to reveal that a Lab representative was in attendance.

During an interview on 11/24/25, at 11:09 a.m. Nursing Home Administrator confirmed the facility failed to ensure that Infection Control meetings had all the required nine multidisciplinary members present at the Infection Control meetings for four of four quarters (Quarters One, Two, Three, and Four).

Plan of Correction - To be completed: 01/12/2026

A new lab representative has been identified. An individual meeting with the new Infection Control Committee Meeting lab representative has been coordinated to provide a summary of the last meeting and the next meeting date.

The NHA has re-educated the Infection Prevention Coordinator regarding the need to have a lab representative at the quarterly Infection Control Committee Meeting and the need to confirm availability and attendance in advance of the meeting date.

Audits will be completed monthly by the NHA and/or designee to ensure a meeting invite has been sent to the lab representative. Attendance will be confirmed following each quarterly meeting. Audits will be completed for 2 meetings or until substantial compliance is achieved.

Results will be reviewed at the quarterly QA meeting.

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