Abington Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarks Summit, Pennsylvania.
- Location
- 100 Edella Road, Clarks Summit, Pennsylvania 18411
- CMS Provider Number
- 395701
- Inspections on file
- 33
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Abington Manor during CMS and state inspections, most recent first.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
Two residents reported ongoing concerns about delayed call bell response times, with one resident experiencing waits of over an hour that led to incontinence episodes. Despite the facility's policy requiring investigation and resolution of grievances within five working days, there was no evidence that these concerns were addressed in a timely manner, and the administrator confirmed the lack of documentation.
Surveyors found that both nursing units had worn, stained, and debris-laden carpeting, with multiple instances of visible stains, substance build-ups, and scattered debris such as paper pieces and food items. A plastic safety lancet was also found on the floor. The Nursing Home Administrator confirmed awareness of these conditions and acknowledged the facility's responsibility to maintain a clean and homelike environment.
A resident with Parkinson's disease and a malignant carcinoid tumor received oxycodone-acetaminophen for pain levels below the physician-ordered threshold, contrary to the care plan and professional standards. The DON confirmed the medication was given outside prescribed parameters.
A resident with COPD and a recent femur fracture was given a full 5 mg dose of oxycodone by an LPN instead of the prescribed 2.5 mg. This error led to an unresponsive episode requiring naloxone administration. The DON confirmed the error and noted the resident's poor renal clearance contributed to the adverse reaction.
The facility failed to prevent and manage pressure ulcers for two residents. One resident developed a pressure ulcer due to the improper use of elbow protectors without documented orders or skin assessments. Another resident's sacral pressure ulcer worsened due to a lack of consistent wound measurements, hindering the evaluation of treatment effectiveness. The Director of Nursing confirmed these deficiencies.
The facility inaccurately coded MDS assessments for two residents, indicating dialysis and insulin treatments that were not administered. The DON confirmed these errors, as no dialysis or insulin was provided to the residents, contrary to what was documented.
A resident at risk for falls due to altered mobility and medication use experienced multiple falls, including one in the bathroom when left unattended by a nurse aide. Despite a care plan intervention requiring staff to stay with the resident in the bathroom, this was not consistently followed, leading to a fall and injuries.
The facility failed to follow physician orders for medication administration for two residents. One resident with diabetes and COPD missed several medications, including insulin and inhalers, while another resident with diabetes did not receive their insulin dose. The Director of Nursing confirmed these lapses, which were identified through record reviews and staff interviews.
A resident was administered Cephalexin without documented symptoms of a UTI and without confirmation of the organism's susceptibility to the antibiotic. Despite the facility's antibiotic stewardship policy, there was no evidence to justify the necessity of the prescription, as confirmed by staff interviews.
The facility failed to date food items in storage, increasing the risk of food-borne illness. Surveyors observed 14 thawed nutritional beverage shakes and two bags of frozen vegetables without proper dating. The food service director confirmed that all food items should be dated to ensure safety and quality.
A facility failed to document the specific circumstances for administering Morphine Sulfate to a resident with end-stage kidney disease, anxiety, and shortness of breath. The MAR lacked clarity on whether the medication was for pain or shortness of breath, as confirmed by the DON, leading to a deficiency in accurate record-keeping.
The facility failed to deliver unopened mail to two residents, violating their right to personal privacy. Both residents, who were cognitively intact, reported instances of receiving opened mail, particularly from medical sources. The Nursing Home Administrator confirmed the residents' rights but lacked documentation to prove compliance with the facility's procedure requiring mail to be delivered unopened within 24 hours.
The facility failed to provide adequate supervision and implement safety measures, resulting in a resident's fall with injury and another resident's unauthorized absence. Staff neglected to activate a chair alarm and did not account for a resident's whereabouts, leading to significant lapses in care.
The facility failed to provide sufficient nursing staff, resulting in a severely cognitively impaired resident falling and injuring himself, and another resident being unsupervised and missing for hours, eventually found at a casino. The facility was unable to demonstrate adequate supervision and care for the residents during the shift in question.
The facility failed to maintain accurate clinical records when an LPN documented administering medications to a resident who was not present in the facility. The ADON confirmed the discrepancy, highlighting a breach in professional standards of nursing documentation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Promptly Resolve Resident Grievances Regarding Call Bell Response
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents regarding call bell response times. According to the facility's grievance policy, concerns should be investigated and the person filing the grievance notified of the resolution within five working days. However, review of the complaint log and resident council meeting minutes showed that concerns about extended call bell response times were raised by two residents in consecutive meetings, and there was no evidence that these grievances were investigated or resolved in a timely manner as required by policy. One resident, who was cognitively intact and had a diagnosis of osteoarthritis, reported that the issue with delayed call bell response had not been resolved and described waiting over an hour for assistance, resulting in episodes of incontinence. The facility was unable to provide documentation showing that the grievance was addressed according to their policy. The Nursing Home Administrator confirmed the lack of timely resolution documentation during an interview.
Failure to Maintain Clean and Homelike Environment on Nursing Units
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment on both Floor 1 and Floor 2 nursing units. During a facility tour, multiple instances of worn, stained, and tattered carpeting were noted throughout four resident hallways. Scattered debris, including white paper pieces, orange chips, and a small solid brown object, was found on the floors. Specific observations included multiple white stains, dark discolorations, and substance build-ups on the carpets, as well as an encrusted orange substance between resident rooms. Additionally, a plastic safety lancet was found on the floor, though the needle was retracted and locked in its protective barrier. Interviews with the Nursing Home Administrator confirmed awareness of the poor condition of the carpeting, including the presence of multiple stains, visible debris, and substance build-ups. The NHA acknowledged the facility's responsibility to ensure a clean and homelike environment for residents. The findings were determined to be in violation of state regulations regarding management, resident rights, and nursing services.
Pain Medication Administered Outside Physician Parameters
Penalty
Summary
The facility failed to provide pain management services consistent with professional standards of practice, the resident's care plan, and physician orders for one resident. The resident, who had diagnoses including Parkinson's disease and a malignant carcinoid tumor, had a care plan goal for pain to be managed within acceptable limits, with interventions to administer pain medications as ordered. Physician orders specified that oxycodone-acetaminophen was to be given only for pain levels rated 5-10, and acetaminophen for pain levels 1-5. A review of the Medication Administration Record showed that the resident received oxycodone-acetaminophen on four occasions for pain levels below the prescribed threshold, specifically for pain scores of 0, 3, and 4, which did not meet the criteria for administration of this medication. The DON confirmed that the medication was administered outside the parameters set by the physician, and acknowledged the facility's responsibility to ensure pain management is provided according to professional standards.
Significant Medication Error: Incorrect Oxycodone Dose Administered
Penalty
Summary
A significant medication error occurred when a resident with chronic obstructive pulmonary disease and a recent femur fracture was administered an incorrect dose of oxycodone. The resident had a physician's order for 2.5 mg (half tablet) of oxycodone every 8 hours as needed for pain, but on the morning in question, an LPN administered a full 5 mg tablet instead of the prescribed half dose. This error was confirmed by both the Medication Administration Record and an employee witness statement, which indicated the nurse forgot to split the tablet. Following the administration of the incorrect dose, the resident experienced a sudden change in mental status, including diaphoresis, a blank stare, and unresponsiveness. Medical staff responded by assessing the resident, obtaining new orders, and administering naloxone (Narcan) to reverse the opioid effects. The resident's condition improved within minutes after intervention. The Director of Nursing confirmed the medication error and noted that the resident's poor renal clearance contributed to the adverse response.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently implement measures to promote healing and prevent the development of pressure sores for two residents. Resident 1, who was severely cognitively impaired and dependent on staff for all activities of daily living, was at risk for pressure sore development. Despite having a care plan that included interventions such as pressure-reducing cushions and regular skin assessments, an open area was identified on the resident's right antecubital area. This was discovered by a nurse aide who noticed the elbow pad was very tight, leading to the development of a pressure ulcer. The facility did not have documented orders or interventions for the use of elbow protectors, and no skin assessment was conducted for potential risks associated with their use. Resident 204 was admitted with a Stage 3 pressure ulcer on the right buttock and coccyx and an intact blister on the right lower back. The care plan included interventions such as enhanced barrier precautions and regular skin assessments. However, the facility failed to document wound measurements for the sacral pressure area, which is crucial for evaluating the effectiveness of the treatment plan. Observations revealed that the resident had an alternating air mattress and elevated heels, but the sacral wound had worsened significantly without proper evaluation or documentation of its progression. Interviews with the Director of Nursing confirmed that the facility did not thoroughly evaluate Resident 204's sacral pressure ulcer for changes and failed to implement interventions to prevent the development of Resident 1's pressure ulcer. The lack of consistent wound measurements and the improper use of protective devices contributed to the deficiencies identified in the care of these residents.
Inaccurate MDS Assessments for Dialysis and Insulin
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For Resident 69, the MDS assessment indicated that the resident received dialysis treatments while at the facility. However, a review of the clinical records and an interview with the Director of Nursing (DON) confirmed that Resident 69 was not receiving dialysis services and had not received any dialysis treatments as a resident at the facility. The MDS was incorrectly coded to reflect dialysis services without a physician's order. Similarly, for Resident 79, the MDS assessment indicated that the resident received three insulin injections in the last seven days. However, further clinical record review revealed no documented evidence of insulin administration during that period. The DON confirmed that Resident 79 did not receive insulin as indicated in the MDS assessment, and the coding was done in error. These inaccuracies in the MDS assessments were identified during a review of clinical records and staff interviews.
Failure to Implement Fall Prevention Plan for Resident
Penalty
Summary
The facility failed to implement a person-centered fall prevention plan for a resident identified as being at risk for falls due to altered mobility and antidepressant medication use. Despite having a care plan in place that included interventions such as encouraging slow position changes and assistance with transfers, the resident experienced multiple falls over a period of time. The resident's fall risk was documented as moderate, with a history of prior falls and a tendency to overestimate or forget limitations. On November 8, 2024, the resident fell in the bathroom when a nurse aide left him unattended to gather hygiene supplies, resulting in a skin tear and a reopened surgical incision. Following this incident, a new intervention was added to the resident's care plan, requiring staff to remain with the resident while in the bathroom. However, during an observation on November 12, 2024, a nurse aide left the resident unattended in the bathroom, contrary to the updated care plan. Interviews with staff, including the Director of Nursing, confirmed the facility's responsibility to ensure the implementation of the care plan interventions, which was not adhered to in this case.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide quality care by not adhering to physician orders for medication administration for two residents. Resident 64, who has diabetes mellitus and COPD, did not receive several prescribed medications on November 7, 2024. These included a morning Accu-check for blood glucose, a dose of Lantus insulin, Spiriva inhaler, Systane Ultra eye drops, and Pregabalin for neuropathy, all scheduled for 6:00 A.M. The failure to administer these medications as ordered was confirmed by a review of the resident's Medication Administration Record (MAR). Similarly, Resident 6, diagnosed with diabetes mellitus and cerebral infarction, did not receive the prescribed Basaglar insulin dose on November 12, 2024, which was scheduled for 6:30 A.M. The Director of Nursing confirmed that the facility did not follow physician orders, resulting in the residents not receiving necessary treatments at the designated times. This deficiency was identified through clinical record reviews, facility policy review, and staff interviews.
Failure to Ensure Drug Regimen Free of Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic medications. The resident, who was admitted with a history of myocardial infarction, was prescribed and administered Cephalexin despite the absence of documented symptoms of a urinary tract infection. A culture laboratory report indicated the presence of Klebsiella oxytoca ESBL and Enterococcus species in the resident's urine, but it did not specify the susceptibility or resistance of these organisms to Cephalexin. Despite this lack of information, the resident received twenty doses of Cephalexin over a five-day period. Interviews with facility staff, including a Certified Registered Nurse Practitioner and the Director of Nursing, confirmed that there was no documented evidence to justify the necessity of the Cephalexin prescription. The facility's policy on antibiotic stewardship requires that culture and sensitivity results be communicated to the prescriber to determine the appropriate course of antibiotic therapy. However, this protocol was not followed, leading to the administration of potentially unnecessary antibiotics to the resident.
Failure to Date Food Items in Storage
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in the food and nutrition services department. During an initial tour of the department, surveyors observed 14 four-ounce thawed nutritional beverage shakes on a refrigerator shelf that were not dated with a thaw or discard date, despite the manufacturer's label indicating they should be used within 14 days of thawing. Additionally, two bags of frozen vegetables in the freezer were not dated. An interview with the food service director confirmed that all food items were supposed to be properly dated to ensure safety and quality.
Failure to Document Medication Administration Circumstances
Penalty
Summary
The facility failed to ensure accurate documentation in the clinical record of a resident, specifically regarding the administration of medication. The resident, who was admitted with diagnoses including end-stage kidney disease, anxiety, shortness of breath, and a need for palliative care, had a physician's order for Morphine Sulfate solution to be administered as needed for shortness of breath or pain. However, the Medication Administration Record (MAR) for the resident did not specify the circumstances under which the narcotic medication should be administered, whether for pain or shortness of breath. An interview with the Director of Nursing (DON) confirmed that the facility did not specify when the narcotic medication should be administered to the resident. The DON acknowledged that there should have been two separate orders to identify if the resident required the medication for shortness of breath or pain. This lack of specification in the MAR led to a deficiency in maintaining accurate records as per professional standards of practice.
Failure to Deliver Unopened Mail to Residents
Penalty
Summary
The facility failed to ensure that mail was delivered unopened to two residents, violating their right to personal privacy. Resident 64, who was cognitively intact with a BIMS score of 15, reported that his mail was sometimes opened before he received it, and on occasions, it was not in the sender's envelope. This resident was admitted with diagnoses including diabetes mellitus and essential hypertension. Similarly, Resident 20, also cognitively intact with a BIMS score of 15 and diagnosed with diabetes mellitus and depression, stated that her mail, particularly from medical sources, was opened without her permission before delivery. The Nursing Home Administrator confirmed the residents' right to receive unopened mail but could not provide documented evidence that Residents 20 and 64 received their mail unopened as required. The facility's written procedure indicated that residents have the right to personal privacy, including receiving unopened mail within 24 hours, unless they request otherwise. This deficiency was identified during a review of clinical records, facility procedures, and interviews with residents and staff.
Failure to Provide Adequate Supervision and Implement Safety Measures
Penalty
Summary
The facility failed to provide adequate staff supervision to timely identify a resident's unauthorized absence and to consistently implement planned safety measures to prevent a fall. Resident 2, who was admitted with Alzheimer's disease and mild dementia, was identified as being at high risk for falls. Despite care planned interventions, including the use of bed and chair alarms, the resident was found on the floor with a significant injury after being left unsupervised in the dining room. The responsible nurse aide admitted to forgetting to activate the chair alarm, and the resident was left unsupervised for nearly two hours before the fall occurred. Resident 1, who was cognitively intact and independent with ambulation, was not accounted for during a shift on March 31, 2024. Multiple staff members failed to notice his absence, and it was later discovered that he had left the facility without signing out. The resident was eventually located at a casino, where he expressed a desire not to return to the facility. The staff's failure to supervise and account for the resident's whereabouts led to a significant lapse in care, as the resident missed several scheduled medication administrations. Interviews with various staff members, including the assistant director of nursing, confirmed the facility's failure to implement safety interventions and provide adequate supervision for both residents. The incidents highlight significant deficiencies in the facility's ability to ensure resident safety and proper supervision, leading to preventable injuries and unauthorized absences.
Insufficient Nursing Staff Leads to Resident Injuries and Unsupervised Absence
Penalty
Summary
The facility failed to provide sufficient nursing staff to consistently provide timely care and supervision necessary to maintain the physical and mental well-being of two residents. Resident 2, who was severely cognitively impaired and at high risk for falls, was found on the floor with a bleeding hand after being left unsupervised in the dining room. The nurse aide responsible for Resident 2's care admitted to forgetting to put the chair alarm on his wheelchair, and the resident was left unsupervised for nearly two hours before the fall occurred. The assistant director of nursing confirmed that the facility failed to implement planned safety interventions and provide adequate staff supervision to prevent the fall and subsequent injury. Resident 1, who was cognitively intact and independent with ambulation, was not located in the facility for many hours on Easter Sunday. The resident did not receive his scheduled medications and blood sugar monitoring throughout the day. Multiple staff members, including a registered nurse and nurse aides, failed to report the resident's absence or locate him. The resident was eventually found at a local casino, where he stated he did not want to return to the facility. The assistant director of nursing and the social worker had the resident sign a handwritten form discharging himself against medical advice. The facility's staffing records for the day revealed that there was insufficient staff to adequately supervise and provide care for the residents. The nursing home administrator and the assistant director of nursing confirmed that the facility was unable to demonstrate the provision of sufficient nursing staff to supervise and provide care as planned and ordered for Resident 1 during the shift in question.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one of four sampled residents. Employee 3, an LPN, documented that she administered medications to Resident 1 at 5:00 PM on March 31, 2024. However, it was later confirmed through staff interviews and a review of the facility's documentation that Resident 1 was not present in the facility at that time and did not receive any medications after 6:00 AM on that date. Employee 3 had reported Resident 1's absence to the RN Supervisor at approximately 4:30 PM but still documented the administration of the medications at 5:00 PM, which was inaccurate and false documentation. This action is in violation of the American Nurses Association Principles for Nursing Documentation and the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145 and 21.148, which require accurate and timely documentation of patient care activities. The ADON confirmed during an interview on April 3, 2024, that Employee 3 did not administer the 5:00 PM medications to Resident 1 as documented. This discrepancy highlights a failure in maintaining accurate medical records and ensuring proper communication among the healthcare team. The incident underscores the importance of adhering to professional standards of practice in nursing documentation to support informed decision-making and high-quality care for residents.
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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