Advanced Care Center Of Butler
Inspection history, citations, penalties and survey trends for this long-term care facility in Butler, Pennsylvania.
- Location
- 115 Technology Drive, Butler, Pennsylvania 16001
- CMS Provider Number
- 396149
- Inspections on file
- 11
- Latest survey
- November 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Advanced Care Center Of Butler during CMS and state inspections, most recent first.
The facility failed to ensure the activities program was directed by a qualified professional. A former CNA was promoted to Activities Director without meeting the necessary qualifications. The CNA was enrolled in coursework for certification but had not yet achieved the required credentials. The facility did not provide evidence of the CNA's qualifications, which was confirmed through staff interviews and document reviews.
The facility did not maintain a full-time Director of Nursing (DON) for three weeks, as the DON was assigned to staff nurse duties on multiple occasions, failing to fulfill full-time DON responsibilities. This was confirmed by staff interviews and a review of staffing documents.
The facility did not notify the State agency of a change in the Nursing Home Administrator (NHA) at the time of the change, as required by regulations. NHA Employee E4 went on medical leave, and Interim NHA Employee E5 took over the role. The facility informed the State agency of this change weeks later, not meeting the requirement for timely notification.
The facility failed to designate a qualified Infection Preventionist (IP) for twelve consecutive months, with the Director of Nursing (DON) or interim DON acting as the IP instead. This was confirmed by both the Nursing Home Administrator and the DON, violating Pennsylvania codes related to the responsibility of the licensee, management, and nursing services.
The facility failed to provide appropriate respiratory care for three residents by not dating oxygen tubing and humidification as required by policy. This was confirmed by staff observations and interviews.
The facility failed to ensure that the Medical Director and Infection Control Coordinator attended the QAPI Committee meetings at least quarterly. The Medical Director or physician designee was absent from the QAPI meetings in November 2023, December 2023, and January 2024. Additionally, the Infection Preventionist, who was also the DON, did not attend the QAPI meetings on multiple occasions between May 2023 and January 2024. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to notify the family of a change in condition in a timely manner for a resident who was transferred to the hospital due to G tube issues. The resident's son discovered the transfer during a visit and was informed by an RN. The Director of Nursing confirmed the failure to notify the family promptly.
The facility failed to provide timely notice of the Notice of Medicare Non-Coverage (NOMNC) for a resident with diagnoses including breast cancer, kidney failure, and falls. The NOMNC indicated that coverage would end on 3/27/24, but the resident was provided and signed the form on the same day, rather than at least two days prior as required. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to maintain the privacy and confidentiality of a resident's health information. A CHF Blood Pressure Log containing the resident's name, blood pressure, pulse, weight, and symptoms was posted on the resident's bathroom door. This was confirmed by an RN during an interview.
A resident with a history of stroke, hemiplegia, and COPD was found wearing two incontinence briefs, against facility policy. The responsible nurse aide was identified and removed from the schedule after a facility investigation confirmed negligence.
The facility failed to provide a written notice of bed hold policy for two residents at the time of transfer to an acute care facility. Interviews with staff confirmed that the policy is reviewed upon admission and families are called during transfers, but no written notice is sent.
The facility failed to develop a baseline care plan within 48 hours for a resident with end-stage kidney disease, dependence on dialysis, and high blood pressure. Despite physician orders for dialysis, the clinical record lacked a care plan addressing these needs, as confirmed by the Case Coordinator.
The facility failed to implement care plans for two residents. One resident with a large open wound did not have a corresponding care plan, and another resident with multiple pressure injuries did not receive the required weekly Braden Scale assessments. These deficiencies were confirmed by staff interviews.
The facility failed to implement a bowel protocol as ordered for a resident with high blood pressure and surgical aftercare needs. Despite physician orders for Milk of Magnesia and Bisacodyl suppository, the resident did not have a bowel movement for four days, and the prescribed medications were not administered. Staff interviews and clinical record reviews confirmed the lapse in following the facility's bowel management policy.
The facility failed to provide adequate pressure ulcer care for a resident with end-stage kidney disease and other conditions. Despite the resident's care plan requiring weekly Braden Scale and wound assessments, these were not completed, resulting in inadequate management of the resident's four Stage 2 pressure ulcers.
The facility failed to conduct and document neurological assessments for a resident with a history of stroke, syncope, and seizure disorder after multiple unwitnessed falls, despite the facility's policy requiring such assessments.
The facility failed to provide consistent and complete communication with the dialysis center for two residents, leading to incomplete Hemodialysis Communication Forms on multiple occasions. This was confirmed by staff interviews and acknowledged by the Director of Nursing.
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days for two residents. One resident received alprazolam for anxiety, and another received olanzapine for dementia-related symptoms, both exceeding the 14-day limit. The Nursing Home Administrator confirmed the non-compliance during an interview.
The facility failed to date opened medications and properly store medications in one of two medication carts observed. Insulin pens for three residents were found without the required labeling, which was confirmed by an LPN and the DON. The facility policy mandates that the expiration date and time be recorded on the pen when a new insulin pen is opened.
The facility failed to implement infection control measures and transmission-based precautions for a resident with Clostridium difficile and VRE. The RN did not perform hand hygiene during a dressing change, and no contact precautions were observed outside the resident's room, despite physician orders.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional for three consecutive months. The Activities Director, a former Certified Nurse Assistant (CNA), was promoted to the position without meeting the necessary qualifications. The CNA was enrolled in coursework to obtain certification as an Activity Professional but had not yet achieved the required certification or qualifications. The facility did not provide evidence that the CNA was licensed or registered as an Activity Professional, eligible for certification as a therapeutic recreation specialist, or had the requisite experience in a therapeutic activities program. This deficiency was confirmed through staff interviews and a review of facility documents, including an invoice indicating the CNA's enrollment in a certification course.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) as the Director of Nursing (DON) on a full-time basis for three consecutive weeks. During this period, the DON was assigned to function as a staff nurse and provide direct resident care on multiple occasions, rather than fulfilling the responsibilities of a full-time DON. Specifically, the DON was assigned as a staff nurse on 10/20/24, 10/31/24, 11/2/24, 11/3/24, 11/5/24, 11/6/24, and 11/7/24. This assignment resulted in the facility not having a full-time DON as required by PA Code: 211.12(b)(c) Nursing services. Interviews with staff, including RN Employee E6 and the Interim Nursing Home Director, confirmed these assignments and the failure to maintain a full-time DON during the specified weeks.
Failure to Timely Notify State Agency of NHA Change
Penalty
Summary
The facility failed to notify the State agency of a change in the Nursing Home Administrator (NHA) at the time of the change, as required by 42 CFR Part 483, Subpart B, section 483.70 (k) (2). During a file review, it was found that NHA Employee E4 was on a medical leave of absence, and Interim NHA Employee E5 had assumed the role of the facility's administrator. Interviews with Registered Nurse Employee E6 and Interim NHA Employee E5 confirmed this change. However, the facility only notified the State agency of this change on 11/11/24, despite the change occurring on 10/24/24, thus failing to meet the requirement of notification at the time of the change.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the infection prevention and control program for twelve consecutive months. The facility's policy indicated that a full-time registered nurse should serve as the Infection Control Coordinator/IP. However, the review of the facility's Infection Preventionist Timeline revealed that the Director of Nursing (DON) or interim DON acted as the IP from May 2023 through May 2024. During interviews, both the Nursing Home Administrator and the DON confirmed that the facility did not have a part-time IP and that the DON was fulfilling the role of IP while also performing her duties as the DON. This failure to have a dedicated IP was in violation of the specified Pennsylvania codes related to the responsibility of the licensee, management, and nursing services.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen management for three residents. Resident R2, who was admitted with diagnoses of heart failure, high blood pressure, and renal insufficiency, was observed wearing 2 liters of oxygen via nasal cannula, but the oxygen tubing was not dated. Similarly, Resident R77, admitted with heart failure, renal insufficiency, and COPD, was observed wearing 3 liters of oxygen via nasal cannula, and the tubing was also not dated. Licensed Practical Nurse (LPN) Employee E2 confirmed that the oxygen tubing for both residents was not dated during an interview. Resident R133, admitted with heart failure, pneumonia, and diabetes, was observed wearing 2 liters of oxygen with humidification, but neither the oxygen tubing nor the humidification was dated. Registered Nurse Employee E7 confirmed this observation. The Director of Nursing later confirmed that the facility failed to provide appropriate respiratory care related to oxygen management for these three residents. The facility's policy required that humidification be labeled with the resident's name, room number, and date, and that tubing be changed weekly, dated, and initialed, which was not adhered to in these cases.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director and Infection Control Coordinator attended the Quality Assurance Process Improvement (QAPI) Committee meetings at least quarterly, as required. Specifically, the Medical Director or physician designee was absent from the QAPI meetings in November 2023, December 2023, and January 2024. Additionally, the Infection Preventionist, who was also the Director of Nursing, did not attend the QAPI meetings on multiple occasions between May 2023 and January 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on May 1, 2024.
Failure to Notify Family of Change in Condition
Penalty
Summary
The facility failed to notify the family of a change in condition in a timely manner for Resident R11. Resident R11 was admitted with diagnoses including adult failure to thrive, atrial fibrillation, and benign prostatic hyperplasia. The resident's care plan indicated that the resident should tolerate tube feedings without complications. However, on 4/18/24, Resident R11 was transferred to the hospital due to issues with the G tube, but the family was not notified by the previous shift. The resident's son discovered the transfer when he visited and was informed by RN Employee E1. Documentation did not include notification of the family by the previous shift. During an interview on 5/2/24, the Director of Nursing confirmed that the facility failed to notify the family of the change in condition in a timely manner. This deficiency was identified for one of three residents reviewed. The failure to notify the family promptly is a violation of resident rights and nursing services regulations as outlined in 28 Pa. Code sections 201.29, 201.14, 211.12, and 211.10.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide timely notice of the Notice of Medicare Non-Coverage (NOMNC) for one of three sampled resident records. Specifically, the NOMNC for Closed Resident Record CR1, who was admitted with diagnoses including breast cancer, kidney failure, and falls, indicated that the effective date coverage of skilled services would end on 3/27/24. However, the resident was provided and signed the NOMNC on the same day, 3/27/24, rather than at least two days prior as required. This deficiency was confirmed by the Nursing Home Administrator during an interview on 5/1/24.
Failure to Maintain Privacy and Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to provide privacy and confidentiality of resident healthcare information for one of eight residents (Resident R128). During an observation in Resident R128's room on 4/30/24, at 10:45 a.m., a Congestive Heart Failure (CHF) Blood Pressure Log was posted on the resident's bathroom door. The log contained the resident's name, blood pressure, pulse, weight, and symptoms from 4/24/24 to 4/30/24. This was confirmed during an interview with Registered Nurse, Employee E7, who acknowledged the failure to maintain the privacy and confidentiality of the resident's health information.
Neglect of Resident by Double Briefing
Penalty
Summary
The facility failed to ensure that a resident was free from abuse and neglect. Resident R5, who had a history of stroke, hemiplegia, and COPD, required partial-moderate assistance for personal hygiene. During morning care, an LPN discovered that Resident R5 was wearing two incontinence briefs, which is against the facility's policy. The resident identified the nurse aide responsible for dressing her as Employee E3. This was the second occurrence of double briefing by the same nurse aide, despite being previously informed that it was not allowed. The facility's investigation concluded that Nurse Aide Employee E3 was negligent in care practices and was subsequently removed from the facility schedules. Interviews with the DON confirmed that the facility failed to protect Resident R5 from neglect. The facility's policy mandates rounding every two hours and prohibits double briefing, but these guidelines were not followed in this instance.
Failure to Provide Written Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold policy for residents at the time of transfer to an acute care facility. This deficiency was identified for two of three residents reviewed. Resident R6, who had diagnoses including diabetes, high blood pressure, and coronary artery disease, was transferred to the hospital for respiratory distress. The clinical record for Resident R6 did not include the required written Bed Hold Policy Notice & Authorization form. Similarly, Resident R14, who had diagnoses including dementia, high blood pressure, and seizure disorder, was transferred to the emergency room due to a painful and abnormal appearance of the left hip. The clinical record for Resident R14 also lacked the required written notice of the bed hold policy. Interviews with facility staff confirmed the deficiency. Social Worker Employee E8 indicated that the bed hold policy is reviewed upon admission and that families are called when residents are transferred to the hospital to see if they want to hold the bed. However, a written notice is not sent at the time of transfer. The Nursing Home Administrator confirmed that the facility failed to provide the required written notice for the two residents reviewed. This failure is in violation of the Code of Federal Regulations (CFR) S483.15(d) and relevant Pennsylvania codes regarding resident rights and staff development.
Failure to Develop Baseline Care Plan for Dialysis Patient
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with end-stage kidney disease, dependence on dialysis, and high blood pressure. The resident was admitted and readmitted on specified dates, with physician orders indicating dialysis on Monday, Wednesday, and Friday. However, a review of the clinical record from 4/5/24 to 4/7/24 showed no baseline care plan addressing the resident's dialysis needs. This deficiency was confirmed by the Case Coordinator during an interview on 5/1/24.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement a resident's plan of care for two residents. Resident R11, who was admitted with diagnoses including adult failure to thrive, atrial fibrillation, and benign prostatic hyperplasia, had a large open wound on the right lower extremity. Despite physician orders for specific wound treatments, the care plan for Resident R11 did not include a plan of care for this wound. This was confirmed by the Case Coordinator, Employee E6, during an interview on 5/2/24. Resident R130, admitted with end-stage kidney disease, dependence on dialysis, and high blood pressure, had four Stage 2 pressure injuries, one of which was present upon admission. The care plan for Resident R130 required weekly Braden Scale assessments, but the clinical record from 4/15/24 to 4/29/24 did not show that these assessments were completed. This failure was confirmed by the Case Coordinator, Employee E6, and the Director of Nursing during interviews on 5/1/24 and 5/2/24, respectively.
Failure to Implement Bowel Protocol as Ordered
Penalty
Summary
The facility failed to implement a bowel protocol as ordered for one resident, identified as Resident R126. The resident, who had diagnoses of high blood pressure and was receiving surgical aftercare following digestive system surgery, had physician orders for Milk of Magnesia (MOM) and Bisacodyl suppository to be administered for constipation. Despite these orders, the clinical record indicated that Resident R126 did not have a bowel movement for four days, from 4/21/24 to 4/25/24, and there was no documentation that the prescribed medications were administered during this period. Interviews with staff, including a Nurse Aide and a Licensed Practical Nurse, revealed that the facility's protocol required communication of bowel movement status between shifts and administration of MOM on the second day without a bowel movement, followed by a suppository on the third day if needed. However, this protocol was not followed for Resident R126, as confirmed by the Director of Nursing during an interview on 5/2/24. The facility's Bowel Management policy, last reviewed in 2024, mandates that each resident be assessed and managed for adequate bowel elimination, with a bowel movement schedule established based on individual patterns. Despite this policy, the facility did not adhere to the prescribed bowel regimen for Resident R126, resulting in a failure to provide the necessary treatment and care according to the physician's orders and the resident's needs. This deficiency was identified during a review of clinical records and staff interviews, highlighting a lapse in the facility's responsibility to ensure proper bowel management for its residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment consistent with professional standards of practice for Resident R130. The resident was admitted with diagnoses including end-stage kidney disease, dependence on dialysis, and high blood pressure. Despite being assessed with a Braden Scale score of 20, indicating no risk for pressure ulcers, the resident's care plan did not include measures for pressure ulcer prevention. The resident's Minimum Data Set (MDS) indicated the presence of four Stage 2 pressure ulcers, one of which was present upon admission. However, the facility did not complete the required weekly Braden Scale assessments or the weekly wound assessments as ordered by the physician. During an interview, the Case Coordinator confirmed that the facility failed to complete the necessary weekly Braden Scale assessments and wound assessments for Resident R130. This failure to adhere to the care plan and physician orders resulted in inadequate pressure ulcer management for the resident, violating the facility's policy on wound prevention and the relevant state codes.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that residents received neurological assessments after incidents involving unwitnessed falls for one of four residents (Resident R14). According to the facility's policy, neurological assessments should be conducted for all residents who have sustained head trauma or have had an unwitnessed fall. These assessments should be documented every 15 minutes for one hour, every two hours for the next six hours, and then every shift for 48 hours. However, Resident R14, who had a history of stroke, syncope, and seizure disorder, experienced multiple unwitnessed falls on 3/11/24, 3/13/24, 3/18/24, and 3/22/24, and no neurological assessments were documented for any of these incidents. During interviews, the Director of Nursing and a Registered Nurse confirmed that neurological assessments should be completed and documented in the resident's electronic record following an unwitnessed fall. Despite this, the facility did not follow its own policy, as evidenced by the lack of neurological assessments in Resident R14's clinical records. This failure was acknowledged by the Director of Nursing, who confirmed that the required assessments were not performed as stipulated by the facility's policy.
Incomplete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents, leading to deficiencies in their care. Resident R76, diagnosed with end-stage kidney disease, dependence on dialysis, and stroke, had incomplete Hemodialysis Communication Forms on six occasions. This was confirmed by a Registered Nurse during an interview. The facility's policy required communication with the dialysis center regarding any changes in weight or fluid gain, which was not adhered to in this case. Similarly, Resident R130, also diagnosed with end-stage kidney disease and dependence on dialysis, had incomplete Hemodialysis Communication Forms on five occasions. This was confirmed by a Unit Clerk during an interview. The Director of Nursing acknowledged the facility's failure to provide consistent and complete communication with the dialysis center for both residents. These actions and inactions led to the identified deficiencies in the residents' care.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days for two residents. Resident R3 was admitted with diagnoses including stroke, hemiplegia, and atrial fibrillation. The resident's physician orders included alprazolam for anxiety, which was administered without a 14-day cut-off date and was discontinued only after exceeding the 14-day duration requirement. Similarly, Resident R13, who was admitted with dementia, anxiety, and depression, had physician orders for olanzapine without a 14-day cut-off date, and the medication was discontinued after exceeding the 14-day limit. The facility's policy on PRN psychotropic drugs, last reviewed in 2024, mandates a 14-day duration limit for such medications unless extended by the prescriber with documented rationale. However, the facility did not adhere to this policy for the two residents. The Nursing Home Administrator confirmed the failure to comply with the 14-day limitation for PRN psychotropic medications during an interview. This deficiency was identified through a review of facility policy, clinical records, and staff interviews.
Failure to Date and Properly Store Medications
Penalty
Summary
The facility failed to date opened medications and properly store medications in one of two medication carts observed (Avalon medication cart). During an observation, it was noted that insulin pens for three residents were stored without a date and time indicating when they were opened. Specifically, Resident R2's Victoza pen, Resident R76's Humalog quick pen, and Resident R126's Novolog Flex Pen were found without the required labeling. This was confirmed by an LPN and later by the Director of Nursing. The facility policy on Insulin Administration - Insulin Pens, last reviewed in 2024, mandates that the expiration date and time be recorded on the pen when a new insulin pen is opened.
Failure to Implement Infection Control Measures and Transmission-Based Precautions
Penalty
Summary
The facility failed to implement measures to prevent potential cross-contamination during a dressing change and did not follow transmission-based precautions as ordered for Resident R130. The facility's policy on infection prevention and control emphasizes the importance of hand hygiene to prevent the spread of infection. However, during an observation, it was noted that the Registered Nurse (RN) did not perform hand hygiene or change gloves after removing the resident's soiled dressing before cleaning the wound and applying a new dressing. Additionally, no contact precautions or personal protective equipment were observed outside Resident R130's room, despite physician orders for continuous contact precautions due to Clostridium difficile and VRE infections. Interviews with staff revealed inconsistencies in the understanding and implementation of isolation precautions. The RN indicated that contact precautions were not necessary as the resident was no longer experiencing diarrhea, while the Director of Nursing (DON) stated that the contact precautions should have been discontinued. However, the facility failed to update the orders and implement the necessary precautions as required. The Nursing Home Administrator confirmed the failure to prevent potential cross-contamination during the dressing change, and the DON acknowledged the lapse in following transmission-based precautions for Resident R130.
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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