Abbeyville Skilled Nursing And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 100 Abbeyville Road, Lancaster, Pennsylvania 17603
- CMS Provider Number
- 395199
- Inspections on file
- 22
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Abbeyville Skilled Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
The facility failed to notify the physician of significant weight gains for two residents, as required by their policy and physician orders. One resident had a 3.5-pound weight gain in one day, and another had a 20-pound gain over two days, but neither physician was notified. These oversights were confirmed by interviews with the Nursing Home Administrator and the Director of Nursing.
A resident with intact cognition reported being hit by a staff member, but the facility failed to investigate the incident. The resident later did not recall the event, and the Director of Nursing confirmed no investigation was conducted, violating state codes on abuse reporting and management responsibilities.
The facility failed to complete the required PASRR for two residents, which is necessary for identifying mental illness or intellectual disabilities and ensuring appropriate placement and services. A resident was readmitted without a completed PASRR, and the NHA confirmed this oversight, violating regulations on clinical records and social services.
A facility failed to implement a baseline care plan for a resident with a Foley catheter upon admission. The resident was admitted with the catheter, but the care plan lacked any documentation addressing its management. This was confirmed by the Nursing Home Administrator during an interview.
The facility failed to notify the State Long-Term Care Ombudsman of emergency hospital transfers for four residents, including those with pneumonia, critical potassium levels, shortness of breath, and acute kidney injury. This deficiency was confirmed through record reviews and staff interviews, with the Nursing Home Administrator acknowledging the oversight.
A facility failed to provide timely interventions and wound monitoring for a resident at risk for pressure ulcers. Despite being identified as at risk, the care plan was delayed, and interventions were not promptly implemented. The resident developed a stage two pressure ulcer, and follow-up skin checks were not conducted as required. The DON confirmed that scheduled wound rounds were not completed, contributing to the deficiency.
The facility failed to implement effective infection control measures, with staff observed not adhering to PPE guidelines, such as wearing N95 respirators, while interacting with COVID-19 positive residents. Additionally, the facility did not conduct contact tracing after a staff member tested positive, contributing to an outbreak on the Arcadia Unit.
A resident with Parkinson's did not receive their prescribed Rytary medication nine times due to pending pharmacy delivery, despite the medication being delivered. The physician was not notified of the missed doses, and the DON could not explain the failure.
A resident admitted for short-term rehabilitation after surgery did not have a baseline care plan established for their surgical wound. This oversight was confirmed by both a licensed employee and the Interim DON, indicating a lapse in the facility's admission procedures.
A resident admitted for short-term rehabilitation after surgery did not receive a shower from admission until mid-August. Interviews with staff, including an LPN and the Interim DON, confirmed the lack of bathing services, despite no clinical reason to withhold them. This issue was cited under nursing services regulations, with previous citations noted.
A resident admitted for short-term rehabilitation after surgery had a surgical wound on the mid-back that was not assessed for signs of infection. Despite physician orders for daily wound care, the treatment was missed on two occasions, and no assessments were documented from admission until the infection was identified. The resident reported increased pain, and a nurse practitioner confirmed an infection, leading to a new treatment plan.
A resident, admitted for post-abdominal surgery therapy and requiring substantial assistance, reported feeling unsafe due to rough handling by a male nurse. Despite the resident's daughter reporting the incident to the charge nurse, the facility failed to conduct a timely investigation as required by their abuse prohibition policy. The Nursing Home Administrator was not informed of the complaint until days later, and no documented evidence of an investigation was provided.
The facility failed to ensure a safe and sanitary environment, as mouse droppings were found in a resident's room and remained unaddressed for hours. Additionally, broken tiles and a hole in a bathroom wall were not reported to maintenance. These issues were confirmed through staff interviews, indicating lapses in communication and environmental management.
A resident with a surgical wound and wound VAC experienced a lapse in care due to the facility's failure to maintain the wound VAC as ordered. The wound VAC was non-functional for nearly a week due to a depletion of canisters, despite the facility's awareness and attempts to obtain the necessary supplies.
The facility failed to have an effective pest control system on the dementia unit. An employee and a resident reported frequent sightings of mice. Mouse droppings were observed on a nightstand, and the pest control logs showed the last visit was on an unspecified date. The Nursing Home Administrator confirmed awareness of the issue.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician of significant weight gains for two residents, as required by their own policy and physician orders. Resident 76 had a physician order to be weighed daily, with instructions to notify the physician if there was a weight gain of 1 pound in one day or 3 pounds in one week. On January 22, 2025, Resident 76 experienced a 3.5-pound weight gain in one day, but there was no evidence in the clinical record that the physician was notified of this change. This was confirmed by an interview with the Nursing Home Administrator. Similarly, Resident 147 had an order for weights to be obtained on Monday, Wednesday, and Friday for monitoring purposes. On November 20, 2024, Resident 147 showed a 20-pound weight gain over two days, yet the clinical record lacked documentation of physician notification. This oversight was confirmed by an interview with the Director of Nursing. These failures to notify the physician of significant weight changes are in violation of the facility's policy and procedure titled Weights and Heights, revised in 2023.
Failure to Investigate Suspected Abuse Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an incident involving suspected abuse of a resident. According to the facility's Abuse Prohibition policy, employees are mandated reporters and must immediately report any reasonable suspicion of a crime against a patient. On October 6, 2024, a resident with intact cognition reported being hit multiple times by a staff member during the evening shift. However, the nursing documentation noted that the resident made false accusations and was unable to confirm the incident when questioned. The resident was educated on not making false accusations, but there was no care plan addressing false accusations, nor was there any other documentation of such behavior in the resident's clinical record. The facility's Director of Nursing confirmed that no investigation was conducted regarding the incident. An interview with the resident in February 2025 revealed that the resident did not remember the incident. The facility's failure to investigate the report of suspected abuse is a violation of the responsibility of the licensee and management as per the relevant state codes. The lack of an investigation into the resident's allegations represents a deficiency in the facility's handling of suspected abuse cases.
Failure to Complete PASRR for Two Residents
Penalty
Summary
The deficiency involves the failure to complete the Preadmission Screening and Resident Review (PASRR) for two residents, Resident 60 and Resident 92, as required by the Omnibus Budget Reconciliation Act (OBRA) of 1987. The PASRR is essential for identifying individuals with mental illness or intellectual disabilities, ensuring appropriate placement, and providing necessary services. Resident 60 was readmitted to the facility in August 2025, but a review of their clinical record did not produce a completed PASRR. The Nursing Home Administrator confirmed via email that the PASRR was not completed for Resident 60. This oversight is a violation of the regulations outlined in 28 Pa Code 211.5(f) regarding clinical records and 28 Pa Code 211.16(a) concerning social services.
Failure to Implement Baseline Care Plan for Foley Catheter
Penalty
Summary
The facility failed to ensure a baseline care plan was in place for a resident with a Foley catheter upon admission. The clinical record review revealed that the resident was admitted to the facility with a Foley catheter on January 14, 2025. However, the care plan for the resident did not include any evidence of a care plan addressing the management of the Foley catheter. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 6, 2025, who acknowledged the absence of a baseline care plan for the resident's Foley catheter.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the Office of the State Long-Term Care Ombudsman regarding emergency hospital transfers for four out of five residents reviewed. Specifically, Residents 12, 29, 78, and 130 were transferred to hospitals for various medical emergencies, including pneumonia, critical potassium levels, shortness of breath, and acute kidney injury. Despite these transfers, the facility did not notify the Ombudsman as required. The deficiency was confirmed through clinical record reviews and staff interviews, revealing that the facility had not notified the Ombudsman of any hospital transfers since September 2024. This oversight was acknowledged by the Nursing Home Administrator during an interview conducted via email. The report also notes that this issue had been previously cited on multiple occasions throughout 2024, indicating a recurring problem with compliance in this area.
Failure to Provide Timely Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide timely interventions for a resident at risk for developing a pressure ulcer and did not conduct timely wound monitoring. The facility's policy on Skin Integrity and Wound Management requires that the plan of care reflect assessment findings and that staff continually observe and monitor patients for changes, implementing revisions as needed. However, for a resident newly admitted with acute respiratory failure, a tracheostomy, and mouth cancer, the facility did not develop a care plan addressing the risk for skin breakdown until three days after the resident was assessed to be at risk for developing a pressure ulcer. The resident's admission assessment noted redness on the sacrum, and the Braden Scale indicated the resident was at risk for pressure ulcers. Despite the resident being identified as at risk, the care plan was delayed, and interventions such as pressure redistribution surfaces and wound treatment were not implemented promptly. Additionally, the facility failed to conduct a follow-up skin check after the resident developed a stage two pressure ulcer on the sacrum. An interview with the Director of Nursing revealed that wound rounds were scheduled but not conducted as planned, and the care plan with interventions was not developed until after the pressure ulcer was identified. This lack of timely intervention and follow-up contributed to the deficiency.
Inadequate Infection Control Measures Observed
Penalty
Summary
The facility failed to implement effective infection prevention and control measures as observed on two of four units, as well as in the reception and Rehab department. The Pennsylvania Department of Health's guidelines recommend the use of NIOSH-approved N95 respirators, gowns, gloves, and eye protection for healthcare personnel entering rooms of patients with suspected or confirmed COVID-19. However, multiple staff members were observed not adhering to these guidelines, with some wearing surgical masks improperly or not at all while interacting with residents, including those on contact and droplet precautions. The facility's policy requires special contact and droplet precautions for residents suspected or confirmed to have COVID-19, including wearing an N95 respirator and keeping the patient's room door closed. Despite this, staff members were observed not following these precautions. For instance, a licensed nurse was seen providing aerosol treatment to a COVID-19 positive resident while only wearing a surgical mask, contrary to the required PPE. Additionally, there was a failure to conduct contact tracing after a staff member tested positive for COVID-19, which could have helped identify potential exposures among staff and residents. The report also highlights an incident where two residents from the Arcadia Unit were hospitalized and tested positive for COVID-19, leading to an outbreak on the unit. Despite the outbreak, the facility did not conduct contact tracing to determine possible contacts of the staff who tested positive, some of whom worked across multiple units. This lack of contact tracing and adherence to PPE guidelines contributed to the facility's failure to manage infection control effectively.
Failure to Administer Prescribed Medication for Parkinson's
Penalty
Summary
The facility failed to administer the prescribed medication Rytary to Resident CL1, who has Parkinson's disease, as per the physician's order. The order, dated November 23, 2024, required the administration of three capsules of Rytary three times a day. However, from November 24 to November 30, 2024, the medication was not administered nine times due to pending delivery from the pharmacy. Despite the pharmacy delivering 27 capsules, the medication was not given, and there was no documentation of the physician being notified about the missed doses. An interview with the Director of Nursing confirmed the lack of notification to the physician and provided no explanation for the failure to administer the medication.
Failure to Establish Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to establish a baseline care plan for a resident who was admitted for short-term rehabilitation following surgery. Upon review of the clinical records, it was found that there was no evidence of a baseline care plan addressing the presence and care of the resident's surgical wound. This deficiency was confirmed through interviews with a licensed employee and the Interim Director of Nursing, both of whom acknowledged that the baseline care plan was not established upon the resident's admission.
Failure to Provide Bathing Services
Penalty
Summary
The facility failed to provide bathing or showering services to a resident who was admitted for short-term rehabilitation following surgery. The clinical record review for this resident showed no evidence of a shower being provided from the time of admission until August 13, 2024. Interviews with a licensed employee and the Interim Director of Nursing confirmed that the resident had not received a shower since admission, despite there being no clinical reason to withhold such care. This deficiency was noted under the 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services, which had been previously cited on multiple occasions.
Failure to Assess Surgical Wound Leads to Infection
Penalty
Summary
The facility failed to assess a surgical wound for signs and symptoms of infection for a resident who was admitted for short-term rehabilitation following surgery. The resident had a surgical wound located on the mid-back, and physician orders upon admission specified that the incision should be cleansed with normal saline, dried well, and left open to air every day shift. However, the treatment was not administered on two specific days, and there was no documented evidence of any wound assessment from the time of admission until the infection was identified. The resident reported increased pain and was seen for complaints of infection to the surgical incision. A nurse practitioner later confirmed an incisional infection and prescribed antibiotics and a new wound care regimen. An interview with the Interim Director of Nursing confirmed that no skin or surgical wound assessments were conducted from the time of admission until the infection was identified, indicating a lapse in the facility's nursing services.
Failure to Investigate Allegation of Rough Handling
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of rough handling by a resident who expressed feeling unsafe. The facility's policy on abuse prohibition requires an investigation to be initiated within 24 hours of receiving a report of suspected or alleged abuse. However, in this case, the investigation was not conducted in a timely manner. Resident CL1, who was cognitively intact and required substantial assistance with toileting, was admitted to the facility for therapy post-abdominal surgery. On the day of the incident, the resident was visibly upset and expressed a desire to leave the facility, citing feelings of unsafety. The resident's daughter reported care concerns involving a male nurse, including inappropriate assistance with toileting and rough handling, to the charge nurse, who assured her that the issue would be reported to a supervisor. Despite these reports, the facility did not provide documented evidence of an investigation into the allegations. The Nursing Home Administrator (NHA) was not informed of the email sent to the compliance department until several days later, and the alleged perpetrator, an agency staff member, was no longer allowed in the facility. The lack of a documented investigation into the resident's allegations of rough handling constitutes a failure to adhere to the facility's policy and regulatory requirements, as outlined in the relevant Pennsylvania Code sections.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in one of its units, as evidenced by multiple observations and staff interviews. During an observation in a resident's room, numerous black pellet-like objects, identified as mouse droppings, were found on the bottom wall vent and the floor beneath the television. Despite the presence of these droppings, they remained in the room hours later, indicating a lack of timely cleaning or pest control measures. Additionally, a separate observation in a bathroom revealed broken tiles and a hole in the bottom wall, which had not been reported to the maintenance director. These deficiencies were confirmed through interviews with a licensed nurse and the maintenance director, highlighting a failure in communication and environmental management within the facility.
Failure to Maintain Wound VAC Due to Supply Depletion
Penalty
Summary
The facility failed to ensure that Resident R1 received treatment and care in accordance with professional standards of practice. Resident R1 was admitted with a surgical wound to the right lower leg and had a wound VAC in place. The physician's order specified that the wound VAC dressing should not be changed by the facility staff and that the resident should be monitored and seen by trauma and acute care for wound VAC changes. However, due to a positive flu test, Resident R1's follow-up appointment was rescheduled, and the wound VAC was not operational for several days due to a depletion of canisters. Despite the facility's awareness of the need for canisters and attempts to obtain them, the wound VAC remained non-functional for nearly a week, as confirmed by staff and the Director of Nursing (DON). The resident confirmed that the wound VAC had not been operational for close to a week, and the facility was unable to maintain the wound VAC as required by the physician's order due to supply issues and vendor changes. The deficiency was further highlighted by multiple progress notes and eMAR entries indicating the wound VAC was off due to the lack of canisters. Staff interviews corroborated the issue, revealing that the central supply was aware of the need for canisters, but the facility was in the process of switching vendors and could not obtain the necessary supplies. The DON confirmed that despite efforts to call other facilities and locate canisters, the wound VAC was not consistently operational since the initial depletion of supplies. This failure to maintain the wound VAC as ordered resulted in a lapse in the resident's prescribed wound care treatment.
Ineffective Pest Control on Dementia Unit
Penalty
Summary
The facility failed to have an effective pest control system on the dementia unit (Arcadia). Employee E4 revealed that mice were a significant issue on the unit, with sightings being a common occurrence both day and night. During a tour of the Arcadia unit, mouse droppings were observed on the nightstand next to a resident's bed. Another resident confirmed frequent sightings of mice in the unit and their room, with the most recent sighting occurring the previous night. The review of pest control logs indicated that the pest control company last visited the facility on an unspecified date. The Nursing Home Administrator confirmed awareness of the ongoing mice problem.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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