Allied Services Meade Street Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilkes Barre, Pennsylvania.
- Location
- 200 S. Meade Street, Wilkes Barre, Pennsylvania 18702
- CMS Provider Number
- 395324
- Inspections on file
- 23
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Allied Services Meade Street Skilled Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not consistently receive physician-ordered Geri-sleeves and ace wraps, as observed and confirmed by both the resident and the DON. The care plan also failed to include all current interventions related to skin integrity and injury prevention.
The facility failed to ensure accurate documentation of controlled medications for four residents, leading to discrepancies in the Medication Administration Record (MAR). Medications such as Tramadol, Oxycodone, and Hydrocodone were removed from the supply without corresponding documentation of administration or return. The Director of Nursing confirmed these discrepancies, indicating a failure to comply with the facility's policy on controlled substance documentation.
A facility failed to accurately document a resident's falls in the MDS assessment, reporting fewer falls than actually occurred. The discrepancy was confirmed by the RNAC and DON, violating medical records and nursing services regulations.
A facility failed to provide nursing services according to professional standards for a resident with hypertension and atrial fibrillation. Despite a physician's order for weekly monitoring of blood pressure and heart rate, there was no evidence that these vital signs were obtained. The DON confirmed the oversight and lack of documentation.
The facility failed to monitor and address significant weight changes for two residents, leading to a deficiency in nutritional care. One resident lost 7.3 lbs. in a week without timely reweight or physician notification, while another lost 5.6 lbs. with delayed nutritional intervention and evaluation. These actions violated the facility's policy on weight monitoring and nutritional interventions.
A facility failed to provide timely pain management for a resident with osteoporosis and peripheral vascular disease. The resident's tramadol medication, scheduled for 6:00 PM, was administered late on six occasions, disrupting her sleep. The DON confirmed the late administration and acknowledged the facility's responsibility to adhere to professional standards and the resident's care plan.
A resident with hypertension and atrial fibrillation experienced medication regimen irregularities due to a failure by the attending physician to act on pharmacist recommendations. The CRNP's ambiguous response and a data entry error led to incorrect hold parameters for Amiodarone HCL, resulting in the medication being withheld inappropriately.
A facility failed to implement a care plan for pressure relieving measures for a resident with a right femur fracture and diabetes. Despite the care plan requiring the resident's heels to be floated over a pillow, observations revealed the heels were directly on the mattress. This was confirmed by both a nurse aide and the DON.
The facility failed to follow physician orders for medication administration for four residents, including administering medications despite blood pressure readings outside prescribed parameters and not documenting vital signs before administration. The DON confirmed the expectation for staff to measure blood pressure and heart rate prior to administering medications.
The facility failed to provide sufficient nursing staff, leading to significant delays in care for residents. Residents reported waiting extended periods for assistance with activities of daily living, such as toileting and getting dressed. The Director of Nursing confirmed that call bells should be answered promptly, but insufficient staffing and lack of assistance from LPNs when short-staffed compromised residents' well-being.
The facility failed to provide nourishing evening snacks to residents, resulting in more than 14 hours between supper and breakfast. Multiple residents confirmed they were not routinely offered snacks and had to request them if needed. Staff interviews corroborated the deficiency.
The facility failed to implement its antibiotic stewardship protocols for two residents, leading to the inappropriate use of antibiotics. The necessary McGeer Assessment Tool was not used before administering antibiotics, resulting in unnecessary doses and subsequent changes in treatment based on culture and sensitivity results.
A resident with type 2 diabetes and dementia refused blood glucose monitoring 46 times due to pain from the needle used. Despite the resident's complaints, the facility did not investigate or address the issue until prompted by surveyors, leading to a deficiency in ensuring resident participation in their treatment plans.
The facility failed to assess a resident's capability to self-administer a saline nasal spray solution, as required by policy. The resident was observed with the nasal spray on her bedside table, and staff confirmed there was no physician order, assessment, or care plan documentation for self-administration.
The facility failed to provide individualized care for a resident with PTSD, inaccurately noting the cause of PTSD in the care plan and not assessing for re-traumatization risks. The DON could not explain the discrepancy between the care plan and medication management notes indicating PTSD due to an abusive relationship.
A resident with diagnoses including abnormalities of gait and muscle weakness received unnecessary doses of Ciprofloxacin (Cipro) for a UTI, despite urine culture results indicating the medication was ineffective. The resident received five unnecessary doses before the medication was changed to Macrobid, and later received two more unnecessary doses of Cipro before it was changed to Ampicillin. The DON confirmed the failure in medication management.
The facility failed to timely notify the physician of abnormal lab results for a resident with a UTI, urinary incontinence, and chronic kidney disease stage three. The resident's urine culture showed resistance to the prescribed antibiotic, but the physician was not notified until over 24 hours later, leading to a delay in addressing the resident's condition.
A resident with achalasia of cardia and dystonia requested a change from the house supplement to a Boost supplement for better taste and increased nutritional support. Despite the request and discontinuation of the house supplement, the Boost supplement was never ordered or provided, leaving the resident without the necessary nutritional support.
Failure to Consistently Apply Physician-Ordered Therapeutic Devices
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered therapeutic devices and preventative measures for a resident. The resident, who was admitted with diagnoses including Bullous Pemphigoid, congestive heart failure, and stage 4 chronic kidney disease, had active physician orders for Geri-sleeves to be applied to both upper extremities every shift and ace wraps to be applied to the lower extremities in the morning and removed in the evening. Review of the care plan revealed that it did not address the order for Geri-sleeves, and thus did not reflect all current interventions related to skin integrity and injury prevention. During observation, the resident was found not wearing the ordered Geri-sleeves or ace wraps. The resident reported that staff did not consistently apply these devices, estimating it was a 50/50 chance they would be put on. The DON confirmed that staff had not consistently followed the physician's orders for application of the Geri-sleeves and ace wraps for this resident.
Controlled Medication Record Discrepancies
Penalty
Summary
The facility failed to implement procedures to ensure the accuracy of controlled medication records for four residents. The facility's policy requires that when a Schedule II-V controlled medication is administered, the licensed nurse must immediately document the date, time, amount administered, signature, and remaining balance on the accountability record. However, discrepancies were found in the records of four residents, indicating a failure to comply with this policy. Resident 61 had a physician's order for Tramadol HCl 50 mg to be administered daily for pain management. On one occasion, the medication was removed from the supply, but there was no documentation in the Medication Administration Record (MAR) to confirm its administration or return, leading to a discrepancy. Similarly, Resident 350 had multiple instances where Oxycodone HCl 5 mg was removed from the supply, but the MAR did not reflect its administration on those dates. The Director of Nursing (DON) confirmed these discrepancies during an interview. Resident 23 and Resident 76 also experienced similar issues with their controlled medication records. Resident 23 had Oxycodone HCl 5 mg removed from the supply without corresponding documentation in the MAR. Resident 76 had Hydrocodone Acetaminophen 5-325 mg removed on two occasions, but there was no evidence of administration in the MAR. The DON acknowledged these discrepancies, confirming the facility's failure to ensure compliance with controlled substance documentation policies.
Inaccurate MDS Assessment of Resident Falls
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident, specifically regarding the number of falls experienced. According to the Resident Assessment Instrument (RAI) User's Manual, the MDS is a federally mandated standardized assessment process used to plan resident care and track changes in a resident's status. The quarterly MDS assessment for a resident, dated December 23, 2024, inaccurately reported the number of falls the resident had experienced since the last assessment. The assessment indicated one fall with no injury and one fall with injury, excluding major injury. However, a clinical record review revealed that the resident had actually experienced three falls during the lookback period, occurring on three separate dates. This discrepancy was confirmed during interviews with the Registered Nurse Assessment Coordinator and the Director of Nursing, who acknowledged that the MDS assessment did not accurately include all falls experienced by the resident. This failure to accurately document the resident's falls is a violation of the relevant medical records and nursing services regulations.
Failure to Monitor Vital Signs as Ordered
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for one resident. Specifically, the facility did not ensure that licensed nurses evaluated and provided nursing care according to physician orders. The deficiency involved a resident with diagnoses of hypertension and atrial fibrillation, who was admitted to the facility with moderately impaired cognition. A physician's order required weekly monitoring of the resident's blood pressure and heart rate, but there was no evidence in the clinical record that these vital signs were obtained as ordered. The Director of Nursing confirmed that the facility did not follow the physician's orders and acknowledged the lack of documentation to support that the required monitoring had been completed. This failure to adhere to professional standards of practice and physician orders was identified during a review of the resident's clinical record and staff interviews, highlighting a deficiency in the facility's nursing services.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to consistently and accurately monitor resident weights, leading to a deficiency in identifying changes in nutritional parameters and implementing timely nutritional interventions for two residents. Resident 24 experienced a 7.3 lb. weight loss within one week, but the facility did not obtain a reweight within 48 hours as per policy. Additionally, there was no documentation of weekly weight monitoring or notification to the attending physician and resident representative about the weight change. The registered dietitian's recommendations for reweight and monitoring were not documented as completed. Resident 90 also experienced a significant weight loss of 5.6 lbs. within one week. However, the facility delayed obtaining nutritional supplement orders and failed to notify the attending physician in a timely manner. The registered dietitian did not complete a nutritional evaluation until 28 days after the weight change. These actions and inactions demonstrate the facility's failure to adhere to its policy regarding timely weight monitoring, reweight verification, physician notification, and nutritional interventions.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident, identified as Resident 61, who was admitted with diagnoses including osteoporosis and peripheral vascular disease. The resident's care plan, initiated in November 2024, included a goal to prevent pain from interfering with daily activities, with interventions such as administering prescribed pain medication and monitoring its effectiveness. However, the facility did not adhere to the scheduled administration time for the resident's tramadol HCI tablet 50 mg, which was prescribed to be given at 6:00 PM daily. The medication was administered late on six occasions between January and March 2025, with delays ranging from over two hours to more than four hours past the scheduled time. Resident 61, who is cognitively intact, reported that the late administration of pain medication disrupted her sleep, as she typically falls asleep between 8:00 PM and 9:00 PM. The Director of Nursing confirmed the late administration of the medication and acknowledged the facility's responsibility to provide pain management consistent with professional standards, the resident's care plan, and her preferences. The facility's policy on pain management emphasizes the importance of timely and appropriate interventions, which were not met in this case, leading to the deficiency.
Failure to Act on Pharmacist-Identified Medication Irregularities
Penalty
Summary
The deficiency involved a failure by the attending physician to act upon pharmacist-identified irregularities in the medication regimen of a resident with hypertension and atrial fibrillation. The resident had moderately impaired cognition and experienced episodes where their heart rate fell below 60 bpm. The consultant pharmacist recommended adding hold parameters to the resident's rate control medications to prevent potential complications. However, the Certified Registered Nurse Practitioner (CRNP) responded ambiguously, failing to specify which medications the hold parameters applied to. A discrepancy was found in the physician's order for Amiodarone HCL, which was revised to include the pharmacist's recommendations. However, a data entry error led to incorrect hold parameters being inputted, specifying a hold if the heart rate was less than 69 bpm instead of the recommended 60 bpm. This error resulted in the medication being withheld when the resident's heart rate was 62 bpm, contrary to the pharmacist's recommendation. The Director of Nursing confirmed the error and the CRNP's failure to accurately respond to the pharmacist's recommendation, leading to delayed and inaccurate medication orders.
Failure to Implement Pressure Relieving Measures
Penalty
Summary
The facility failed to implement a resident's care plan for pressure relieving measures for one resident out of 25 sampled. Resident 85, admitted with a right femur fracture and diabetes, had a care plan indicating a potential for skin breakdown due to altered mobility. The care plan, dated March 8, 2024, required the resident's heels to be floated over a pillow while in bed. However, observations on May 2, 2024, at 8:50 AM and 12:15 PM revealed the resident's heels were directly on the mattress. This was confirmed by a nurse aide and the director of nursing, despite the Task Report from March 2024 through May 2, 2024, indicating the need for the intervention.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide person-centered care consistent with professional standards of practice by not following physician orders for medication administration for four residents. Resident 100, who had diagnoses including heart failure and hypertension, received Metoprolol Tartrate on four occasions despite blood pressure readings being lower than the physician-prescribed parameters. The Director of Nursing (DON) confirmed that it is the facility's responsibility to administer medication within the parameters of a physician's orders. Resident 85, diagnosed with hypotension, had a physician order for Midodrine with specific parameters to hold the medication if systolic blood pressure was greater than 130. However, the medication was administered daily without documented evidence that staff obtained the resident's blood pressure prior to administration. Additionally, there was a delay in administering the medication on April 1, 2024, due to awaiting delivery. The DON confirmed that staff should measure blood pressure before administering medication. Resident 69, with diagnoses including epileptic seizures and heart failure, received Midodrine HCL despite blood pressure readings above the physician-prescribed parameters on multiple occasions. Conversely, the medication was held on dates when the systolic blood pressure was below 120. Resident 90, with chronic diastolic congested heart failure and hypotension, had no evidence of heart rate checks before administering Metoprolol Tartrate and received Midodrine HCL despite blood pressure readings above the prescribed parameters. The DON confirmed that staff should measure blood pressure and heart rate before administering medications with specific parameters.
Failure to Provide Sufficient Nursing Staff
Penalty
Summary
The facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality care to residents. This was evidenced by observations, clinical record reviews, and interviews with staff and residents. Specifically, residents were left waiting for extended periods for assistance with activities of daily living, such as toileting and getting dressed. For instance, a resident was observed ringing their call bell for 26 minutes without receiving assistance, while two LPNs were seated at the nursing station. Another resident reported waiting over 45 minutes for help to use the toilet, and another resident stated they had to wait an entire morning and most of the afternoon for assistance to get dressed and out of bed. These delays were attributed to insufficient staffing levels and the lack of assistance from LPNs when the facility was short-staffed. Resident 78, who was cognitively intact and required extensive assistance with activities of daily living, reported waiting over 45 minutes for help to use the toilet. Resident 80, who was moderately cognitively impaired and also required extensive assistance, stated they waited approximately 5.5 hours for help to get dressed and out of bed. Resident 94, who was cognitively intact and required assistance for transfers and toileting, mentioned that they often had to transfer themselves to the toilet due to long wait times for staff assistance. Resident 161, who was cognitively intact and required the assistance of two staff members for bed mobility, transfers, and toileting, reported having to yell for help because their call bell was not answered promptly. The Director of Nursing (DON) confirmed that call bells were supposed to be answered promptly and that sufficient nursing staff should be deployed to ensure residents' needs are met in a timely manner. However, the facility's failure to provide adequate staffing and the lack of assistance from LPNs when the facility was short-staffed led to significant delays in providing necessary care to residents, thereby compromising their mental and physical well-being.
Failure to Provide Evening Snacks
Penalty
Summary
The facility failed to ensure the provision of a nourishing evening snack when more than 14 hours elapsed between the supper meal and breakfast the next day for eight residents. The facility's policy indicated that a variety of snacks should be available throughout the day and that residents should be offered a nutritious bedtime snack. However, observations and interviews revealed that snacks were not routinely offered to residents in the evening. Specifically, during a tour of the facility, no snacks were observed to have been provided to residents on the fourth floor. Multiple residents confirmed that they were not offered snacks in the evening and had to request them if they wanted one. The Resident Council Meeting minutes also indicated that most residents were not being offered snacks after dinner. Interviews with staff, including a nurse aide and the foodservice director, confirmed that snacks were supposed to be available but were not being routinely offered. The foodservice director acknowledged that there was a gap of more than 14 hours between the evening meal and breakfast the next day and confirmed that bedtime snacks should be offered to residents. This deficiency affected eight residents who were part of the sample, and it was corroborated by both resident statements and staff interviews.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use for two residents. For Resident 54, the facility did not complete and apply the McGeer Assessment Tool for a Urinary Tract Infection (UTI) before administering Ceftriaxone. The resident was suspected of having a UTI based on symptoms and a urinalysis, but the McGeer criteria were not met, and the antibiotic was administered before the culture and sensitivity (C&S) results were obtained. The C&S results later showed resistance to Ceftriaxone, leading to unnecessary doses of the antibiotic and a subsequent change in medication after the resident was sent to the Emergency Department (ED) for evaluation due to worsening symptoms and resistance to the initial antibiotic treatment. The resident received five unnecessary doses of Ceftriaxone before the appropriate antibiotic was administered based on the C&S results. For Resident 61, the facility also failed to use the McGeer Assessment Tool before initiating antibiotic therapy. The resident was suspected of having a UTI based on symptoms and a urinalysis, but the McGeer criteria were not fully met. Despite this, the resident was prescribed Ciprofloxacin (Cipro) before the C&S results were available. The C&S results later indicated that Cipro was not effective against the identified bacteria, leading to unnecessary doses of the antibiotic and a subsequent change in medication. The resident received five unnecessary doses of Cipro before the appropriate antibiotic was administered based on the C&S results. The facility's failure to follow its Antibiotic Stewardship policy and the McGeer Criteria for initiating antibiotic therapy resulted in the inappropriate use of antibiotics for both residents. This failure was confirmed through a review of clinical records, facility policies, and staff interviews, which revealed that the necessary assessment tools were not used to ensure the clinical necessity of the antibiotics administered. The Director of Nursing was unable to provide documented evidence that the McGeer Assessment Tool was used for either resident, leading to the inappropriate administration of antibiotics and the need for subsequent changes in treatment based on C&S results.
Failure to Address Resident's Pain and Preferences in Diabetes Management
Penalty
Summary
The facility failed to ensure that residents are consistently afforded the right to participate in their treatment plans, specifically regarding diabetes management for one resident. Resident 36, who has type 2 diabetes mellitus and dementia, refused blood glucose monitoring on 46 occasions between February and April 2024. The refusals were due to the pain caused by the needle used for blood sugar checks, which the resident reported to the nursing staff. Despite the resident's complaints, the facility continued to use the painful needle without attempting to address the issue or discover the reason for the refusals until prompted by surveyors. During an interview, the Director of Nursing (DON) confirmed that the facility had not investigated the resident's refusals or attempted to use a different needle until the surveyor's inquiry. The resident's Medication Administration Record showed no refusals prior to February 2024, indicating a change in the resident's willingness to participate in blood glucose monitoring. The facility's failure to address the resident's pain and preferences for diabetes management led to the deficiency noted in the report.
Failure to Assess Resident's Capability to Self-Administer Medication
Penalty
Summary
The facility failed to determine a resident's capability to self-administer medication, specifically a saline nasal spray solution, for one of the 25 residents reviewed. The facility's policy requires an interdisciplinary team (IDT) assessment and documentation before a resident can self-administer medication. However, Resident 26, who was cognitively intact with a BIMS score of 14, was observed with an opened saline nasal spray bottle on her bedside table. The resident reported that nursing staff left the bottle for her to self-administer, and she had been using it for approximately two months without an IDT assessment or documentation in her care plan. Further observations confirmed the saline nasal spray bottle remained on the resident's bedside table, and the physician's order for the nasal spray had been discontinued. Employee 1, a licensed practical nurse, confirmed that there was no physician order, no self-administration assessment, and no care plan documentation for the resident's use of the saline nasal spray. The facility's failure to follow its policy on self-administration of medications led to this deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide individualized care for a resident diagnosed with PTSD. Resident 21, who had a history of trauma related to an abusive relationship, was admitted with diagnoses including PTSD. The resident's care plan inaccurately noted PTSD related to a car accident, and interventions included enlisting family, offering a change of scenery, reminiscing about past events, and using social services as needed. However, the care plan did not accurately reflect the resident's history of abuse or assess the risk of re-traumatization. A clinical record review revealed discrepancies between the resident's care plan and medication management notes from an outside provider, which indicated PTSD due to an abusive relationship. The Director of Nursing (DON) was unable to explain the discrepancy or provide evidence that the resident was accurately assessed for re-traumatization risks or screened for triggers. This failure to provide trauma-informed care led to the deficiency noted in the report.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs. Resident 61, who had diagnoses including unspecified abnormalities of gait and mobility and muscle weakness, was administered Ciprofloxacin (Cipro) for a suspected urinary tract infection (UTI) based on a nursing progress note dated February 13, 2024. However, the urine culture results received on February 16, 2024, indicated that Cipro was not effective against the identified enterococcus species. Despite this, the resident received five unnecessary doses of Cipro before the medication was discontinued and replaced with Macrobid, as per the new physician's order on February 16, 2024. The resident's medical administration record (MAR) confirmed the administration of these unnecessary doses of Cipro. The issue recurred when another physician's order dated February 29, 2024, prescribed Cipro again for a UTI, despite urine culture results on March 1, 2024, showing that Cipro was not indicated for the enterococcus species present. The resident received two more unnecessary doses of Cipro before the medication was changed to Ampicillin on March 1, 2024. The Director of Nursing (DON) confirmed during an interview on May 3, 2024, that Resident 61 was not free from unnecessary antibiotic medications, highlighting a failure in the facility's medication management and review processes.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to timely notify the physician of abnormal lab results for Resident 54. The resident, who had diagnoses including a urinary tract infection, urinary incontinence, and chronic kidney disease stage three, was ordered to have UA/C&S laboratory work. The urine culture results, dated October 21, 2023, revealed abnormal findings of greater than 100,000 colonies/ml of Klebsiella pneumoniae, an ESBL-producing organism, which indicated resistance to the antibiotic ceftriaxone that the resident was currently receiving. Despite these critical findings, the nursing staff did not notify the physician until October 22, 2023, at 6:44 PM, which was beyond the 24-hour timeframe stipulated by the facility's policy for addressing abnormal lab results. The delay in notifying the physician resulted in a failure to promptly address the resident's condition, which included behaviors and poor intake of food, fluids, and medications. The Director of Nursing confirmed that the laboratory results are sent to both nursing and the physician and acknowledged that the C&S results were not addressed in a timely manner. Consequently, new orders were received to send the resident to the Emergency Department for evaluation, highlighting the deficiency in the facility's response to critical lab results.
Failure to Provide Nutritional Supplement as Requested
Penalty
Summary
The facility failed to provide a nutritional supplement that accommodated a resident's preferences. Resident 91, who has achalasia of cardia and dystonia, was initially prescribed a house supplement 2.0 at 120 ml twice a day. However, the resident frequently refused this supplement and consumed only 50% of it when taken. On March 21, 2024, at the resident's request, the house supplement was discontinued, and a Boost supplement was to be added to her breakfast and dinner trays for increased nutritional support. Despite this change, the Boost supplement was never ordered or provided to the resident. During an interview on May 1, 2024, Resident 91 confirmed that she had not received the Boost supplement as discussed. An observation on May 2, 2024, further confirmed that the Boost supplement was not present on her breakfast tray, and her meal tray ticket did not indicate that it was ordered. Employee 3, a registered dietitian, confirmed that the Boost supplement was not ordered or provided, resulting in the resident not receiving the necessary nutritional support as planned.
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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