Advanced Health Care Of Hanover
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethlehem, Pennsylvania.
- Location
- 3370 High Pointe Boulevard, Bethlehem, Pennsylvania 18017
- CMS Provider Number
- 396150
- Inspections on file
- 14
- Latest survey
- June 29, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Advanced Health Care Of Hanover during CMS and state inspections, most recent first.
Staff did not implement or document the use of a physician-ordered Dynasplint device for a resident with limited range of motion, despite clear orders and therapy recommendations. The resident, who was dependent on staff and had multiple medical conditions, did not receive the prescribed intervention to maintain or improve joint movement.
Surveyors found that the facility did not include required interventions in the care plans for three residents, despite their clinical assessments identifying needs such as vision, nutrition, activities of daily living, communication, dental care, and psychotropic drug use. The DON confirmed these omissions during interviews.
The facility did not consistently follow physician orders for daily weights and vital sign assessments for four residents with conditions such as heart failure, kidney disease, and high blood pressure. Required weights were not documented on multiple days, and a blood pressure medication was administered without evidence that heart rate was checked as ordered. The DON confirmed the lack of documentation for these required assessments.
Two residents who were transferred to the hospital after a change in condition did not receive written notification about the bed hold policy or the reasons for their transfer, nor was Ombudsman information provided. Documentation confirming that these notifications were given was absent, as verified by the Administrator.
A resident's Quarterly MDS assessment was not completed and electronically transmitted to CMS within the required 14-day timeframe. This deficiency was confirmed through clinical record review and interview with the DON.
A resident who was dependent on staff for personal hygiene and bathing was observed on multiple occasions with long and dirty fingernails, and there was no evidence that staff offered or provided assistance with nail care, despite the resident's request and care plan requirements. The DON confirmed that nail care should be provided during routine care.
A resident with chronic kidney disease and heart failure, who was cognitively intact, was not served her preferred breakfast items as indicated on her menu selection form. Instead of the requested pancakes and sausage, she received eggs on a tortilla, fruit, hot tea, and milk, and was observed having difficulty eating the meal. The Administrator confirmed that dietary staff were expected to follow residents' menu selections.
A resident with a recent upper arm fracture, osteoarthritis, and vision problems was not provided with the adaptive eating equipment and assistance specified in her care plan and therapy documentation. Observations showed she did not receive the required inner lip plate, was given incorrect utensils, and her food was not cut, resulting in visible difficulty managing her meals.
A resident with metabolic encephalopathy and a left BKA was admitted with documented intact skin, but later reported an unassessed and unchanged bandaged area on the right lower extremity. Staff failed to document identification or assessment of this impaired area for eight days following admission.
A facility failed to provide a resident's clinical record to their legal representative within the required timeframe. The resident was discharged, and a request for the records was made, but the facility delayed sending the information for several months, violating resident rights under 28 PA. Code 201.29(a).
A facility failed to assist a resident with mouthcare, despite the resident's need for help due to limited mobility and medical conditions such as encephalopathy and heart failure. There was no documentation of assistance or refusal, as confirmed by the DON.
A facility failed to implement a physician's order for a resident with encephalopathy, heart failure, and muscle weakness. The order required a stat urine sample for urinalysis, but there was no evidence it was obtained. The DON confirmed the lapse in following the medical directive.
A resident with chronic heart failure did not receive the prescribed medication Entresto from January 4 to January 8 due to a delay in pharmacy services. The medication was ordered to be administered twice daily starting January 3, but was not provided until January 9, highlighting a deficiency in the facility's pharmaceutical services.
The facility failed to maintain sanitary food storage conditions. Observations revealed undated baking chocolate powder, improperly stored raw chicken and shrimp, and undated raw pork and turkey. A scoop was found in direct contact with flour, and funnels and a Styrofoam bowl were in direct contact with salt and pepper. Additionally, there was no thermometer in the dry storage room, contrary to facility policy.
A facility failed to complete a Discharge MDS assessment within the required timeframe for a resident who was hospitalized. The assessment, which should have been completed and transmitted within 14 days after the resident's discharge, was delayed until July 3, 2024. This deficiency was confirmed by the Regional President of Operations.
The facility did not follow physician's orders for daily weight monitoring for two residents with chronic conditions. One resident's weight was not documented on a specific date, while another resident's weights were missing on two separate dates. The Regional President of Operations confirmed the absence of documentation.
A facility failed to monitor and document the hemodialysis access site for a resident with end-stage renal disease, as required by their policy. The policy required assessments every shift, but records showed no evidence of such assessments since late June. This was confirmed by the Regional President of Operations.
The facility did not verify the professional licenses and registrations for two newly hired staff members, a Registered Nurse and a nurse aide, before they began working. This oversight was confirmed by the Regional President of Operations and violated the facility's policies and state regulations.
Failure to Implement and Document Physician-Ordered ROM Device
Penalty
Summary
A deficiency was identified when staff failed to implement and document an orthopedic surgeon's order for a Dynasplint device to maintain or improve range of motion in a resident with heart failure, osteoarthritis of the right hand, and vision loss. The resident was alert, dependent on staff for activities of daily living, and had a limitation in range of motion in one arm. The order specified that the Dynasplint should be applied to the right elbow for 30 minutes three times daily after meals, as noted in the occupational therapy treatment plan. However, there was no documented evidence that staff ensured the Dynasplint was in place as ordered. This was confirmed by the Administrator during an interview.
Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all identified needs for three residents, as determined through clinical record review and staff interviews. For one resident with diabetes, lower limb cellulitis, and gastro-esophageal reflux disease, the Minimum Data Set (MDS) Care Area Assessment (CAA) summary indicated that vision, activities of daily living, dental care, and nutrition should be addressed, but there was no documented evidence that interventions for these areas were included in the care plan. Another resident with hearing loss, high cholesterol, and a recent total knee replacement had communication, nutrition, and activities of daily living identified as care areas in the MDS CAA summary, yet these were not reflected in the care plan documentation. A third resident with a diagnosis of depression was noted in the MDS CAA summary to require care plan interventions for psychotropic drug use. Review of the medication administration record showed the resident received an antidepressant over several months, but there was no documentation of interventions related to psychotropic drug use in the care plan. The Director of Nursing confirmed during interviews that the identified care areas were not addressed in the care plans for these residents.
Failure to Implement Physician Orders for Weights and Vital Signs
Penalty
Summary
The facility failed to implement physician orders for four residents, as evidenced by a review of facility policy, clinical records, and staff interviews. For three residents with diagnoses including heart failure, kidney disease, and diabetes, physician orders required daily weights and notification to the physician if specific weight gains occurred. However, the Medication Administration Records (MAR) for these residents showed multiple days where weights were not documented as obtained. Additionally, for a resident with high blood pressure, staff were ordered to check the heart rate prior to administering a blood pressure medication and to withhold the medication if the heart rate was below a certain threshold. The MAR indicated that the medication was administered on several occasions without documented evidence that the heart rate was assessed beforehand. The Director of Nursing confirmed in interviews that there was no documented evidence that the required daily weights or heart rates were obtained according to physician orders. The facility's policy on medication administration required staff to follow written physician orders and document vital signs as indicated, but this was not consistently done for the residents in question.
Failure to Provide Required Written Notification of Bed Hold Policy and Transfer
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the bed hold policy and the reasons for transfer, including Ombudsman information, when two residents were transferred to the hospital following a change in condition. Clinical record reviews for both residents showed no documentation that such notifications were given at the time of transfer. During an interview, the Administrator confirmed that there was no evidence that the required notices were sent to the residents or their responsible parties.
Failure to Timely Complete and Transmit MDS Assessment
Penalty
Summary
The facility failed to complete and electronically transmit the encoded Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day timeframe for one resident. Clinical record review showed that the resident had a Quarterly MDS assessment that remained incomplete and had not been transmitted as required. This was confirmed during an interview with the Director of Nursing, who acknowledged that the MDS assessment had not been completed and transmitted within the mandated period.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including heart failure and metabolic encephalopathy, who was dependent on staff for personal hygiene and bathing, was observed on two consecutive days with long and dirty fingernails. The resident's clinical record and care plan indicated a need for staff assistance with activities of daily living (ADLs), including grooming and nail care. Despite this documented need, there was no evidence that staff offered or provided assistance with trimming and cleaning the resident's nails. The resident confirmed in an interview that he would like his nails to be trimmed and cleaned and that staff had not offered to do so. The DON confirmed that nail care should be provided during routine care and as needed.
Failure to Provide Resident with Preferred Meal Items
Penalty
Summary
The facility failed to provide a resident with her preferred breakfast items as indicated on her menu selection form. The resident, who had chronic kidney disease and heart failure and no cognitive impairment, had requested pancakes and sausage for breakfast. However, she was served eggs on a tortilla, fruit, hot tea, and milk instead. Observation showed the resident had difficulty eating the meal provided and expressed a preference for the items she had originally selected. The Administrator confirmed that the dietary department was expected to follow residents' menu selections as identified on the weekly menu selection form.
Failure to Provide Required Adaptive Eating Equipment and Assistance
Penalty
Summary
A deficiency was identified when a resident with a recent upper arm fracture, osteoarthritis in the dominant hand, and vision problems was not provided with the adaptive eating equipment and assistance specified in her care plan and occupational therapy documentation. The care plan and therapy notes indicated the need for an inner lip plate, built-up utensils, visual cues, and staff assistance to cut food at every meal. Despite these documented needs, observations over multiple meals showed that the resident did not receive the required inner lip plate, was given weighted rather than built-up utensils, and her food was not cut into pieces as needed. During these observed meals, the resident was seen struggling to manage her food, having difficulty picking up and cutting items, and lacking the adaptive equipment and assistance outlined in her care plan. The NHA confirmed that the adaptive equipment should have been provided, but it was not in place during the observed meal times.
Incomplete Medical Record Documentation for Resident Skin Assessment
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for one resident. The resident, who had a history of metabolic encephalopathy and a left below-the-knee amputation, was admitted with skin assessments indicating intact skin and no open areas. However, the resident later reported to a nurse practitioner that a bandaged area on the right lower extremity had not been changed or assessed by staff since admission. Upon assessment, a treatment was prescribed for the area. There was no documentation in the clinical record that staff had identified or assessed the impaired area from admission until eight days later.
Delayed Provision of Clinical Records
Penalty
Summary
The facility failed to provide a copy of a discharged resident's clinical record within the required timeframe. A legal representative requested a copy of the clinical record for a resident who was discharged on May 29, 2024. The request was made on August 29, 2024, but the facility did not fax the requested information until December 10, 2024. This delay was confirmed by the Nursing Home Administrator during an interview on March 4, 2025. This deficiency is a violation of 28 PA. Code 201.29(a), which pertains to resident rights, specifically the right to access or purchase copies of their records.
Failure to Assist Resident with Mouthcare
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required help with mouthcare. The resident, who had diagnoses including encephalopathy, heart failure, and muscle weakness, was assessed as alert but with limited mobility in the right upper extremity, necessitating assistance with mouthcare. However, there was no documented evidence that the resident received this assistance, nor were there any records of the resident refusing such care. This deficiency was confirmed through a clinical record review and an interview with the Director of Nursing, who acknowledged the lack of documentation.
Failure to Implement Physician's Order for Urine Sample
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with encephalopathy, heart failure, and muscle weakness. The order, dated January 6, 2025, required staff to obtain a stat urine sample for urinalysis to rule out an infection. However, there was no documented evidence that the urine sample was obtained as ordered. During an interview on February 19, 2025, the Director of Nursing confirmed that the urine sample was not obtained as per the physician's order, indicating a lapse in following the prescribed medical directives.
Failure to Provide Timely Medication
Penalty
Summary
The facility failed to ensure the timely provision of physician-ordered medications for a resident. The resident, who was admitted with chronic heart failure, gout, and deconditioning, had a physician's order for the medication Entresto to be administered twice daily starting January 3, 2025. However, a review of the Medication Administration Record (MAR) for January 2025 revealed that the medication was not provided by the pharmacy until January 9, 2025. As a result, the resident did not receive the prescribed medication from January 4 through January 8, 2025. This lapse in medication administration was identified during a clinical record review, indicating a failure in the facility's pharmaceutical services to meet the needs of the resident as required by federal and state regulations.
Plan Of Correction
Corrective Action for cited Resident: Resident #1 was identified and discharged the facility on January 10th, 2025. Other Residents at Risk: An Audit was completed for patients residing in the facility for pharmacy concerns and pharmacy concerns corrected. Systemic Change: Licensed nurses educated on facility policy regarding the review of medication administration and the process to notify pharmacy and on call provider when medication is unavailable. Ongoing Monitoring: DON/designee will audit the EMAR administration record weekly x4 and monthly x2. The DON/Designee will provide in-service and training if deficient practice is noted. The DON/Designee will present the findings of these audits to the QA Committee for review and recommendations. DON is responsible for maintaining compliance.
Food Storage Sanitation Deficiency
Penalty
Summary
The facility failed to store food under sanitary conditions in the kitchen, as observed during a survey. A review of the facility's Food Storage policy, last reviewed in April 2024, indicated that a thermometer should be present in the dry storage room and that scoops should not be stored in food containers. However, during an observation in July 2024, it was found that a container of baking chocolate powder was not dated after being removed from its original package. In the walk-in refrigerator, raw chicken was stored over raw shrimp, and both were not dated with a pull date after being removed from the freezer. Similarly, raw pork and turkey were also not dated with a pull date. A scoop was found in direct contact with flour in a bulk bin, and funnels were in direct contact with salt and pepper in the dry storage room. Additionally, a Styrofoam bowl was in direct contact with salt in another container, and there was no thermometer in the dry storage room. The Director of Dietary confirmed that the items should have been dated.
Failure to Timely Complete MDS Assessment for Hospitalized Resident
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment in a timely manner for a resident who was hospitalized. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a Discharge assessment is required when a resident is admitted to a hospital or another care setting, and it must be completed and transmitted within 14 days after the Assessment Reference Date (ARD). In this case, the resident was admitted to the facility and later hospitalized, but the Discharge MDS was not completed until July 3, 2024, which was beyond the required timeframe. This deficiency was confirmed during an interview with the Regional President of Operations on the same day.
Failure to Implement Physician's Orders for Daily Weights
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to a deficiency. Resident 4, who was admitted with chronic kidney disease and heart failure, had a physician's order for daily weight monitoring starting June 18, 2024. However, there was no documented evidence of a weight being obtained on June 21, 2024. Similarly, Resident 25, admitted with end-stage renal disease and heart failure, had a physician's order for daily weight monitoring starting June 21, 2024. There was no documented evidence of weights being obtained on June 23 and 30, 2024. An interview with the Regional President of Operations confirmed the lack of documentation for these dates, indicating that the weights were neither obtained nor refused by the residents.
Failure to Monitor Hemodialysis Access Site
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident receiving hemodialysis, as required by their policy. The policy, last reviewed in April 2024, mandates that all patients receiving hemodialysis have their access site assessed every shift for appearance, signs of infection, drainage, bleeding, and bruit and thrill, with documentation in the treatment administration record (TAR). However, a review of the clinical records for Resident 101, who was readmitted with diagnoses including end-stage renal disease and congestive heart failure, revealed no evidence of such assessments being conducted or documented since June 27, 2024. This was confirmed by the Regional President of Operations during an interview on July 3, 2024.
Failure to Verify Licenses for New Hires
Penalty
Summary
The facility failed to adhere to its policy on verifying professional licenses and registrations for new hires, leading to a deficiency. Specifically, two out of five newly hired employees, a Registered Nurse and a nurse aide, began working without their licenses or registrations being verified as required by the facility's policy. The Registered Nurse started employment on May 24, 2024, but the inquiry to the state licensure board was not completed until July 2, 2024. Similarly, the nurse aide began working on May 23, 2024, without any inquiry to the state nurse aide registry. This oversight was confirmed by the Regional President of Operations during an interview on July 3, 2024. The facility's failure to conduct these verifications was in violation of their own policies and procedures, as well as state regulations.
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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