Allied Services Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 303 Smallacombe Drive, Scranton, Pennsylvania 18501
- CMS Provider Number
- 396074
- Inspections on file
- 30
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Allied Services Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with muscle weakness, difficulty walking, incontinence, and documented moisture-associated skin damage was admitted with hospital recommendations for a low air loss bed, barrier products, frequent repositioning, and use of a pressure-relieving cushion. Facility staff performed Braden Scale assessments that inaccurately scored the resident as low risk, documenting that the resident could move freely with minimal assistance despite therapy records showing extensive to maximal assistance needs for bed mobility and transfers. Admission skin findings of redness and rashes on the groin, buttocks, sacrum, coccyx, and heel were not documented with the detailed descriptions required by facility policy. Progress notes later acknowledged risk for skin breakdown but focused on educating the cognitively impaired, dependent resident to reposition himself, rather than ensuring staff-assisted repositioning and full implementation of pressure-relieving interventions. An unstageable pressure injury was subsequently identified on the resident’s right gluteal area, demonstrating that the facility failed to accurately assess pressure injury risk, perform thorough skin assessments, and implement appropriate preventive measures.
A resident with end stage COPD and a Foley catheter was admitted without documented clinical justification for the catheter's continued use. Facility policy requiring assessment and physician notification was not followed, and after the catheter was removed, required bladder assessments and a voiding trial were not documented. The resident subsequently experienced multiple falls while attempting to toilet, and there was no supporting documentation for the continence care plan.
A resident with malnutrition and dementia experienced significant weight loss, but staff did not complete a timely nutritional reassessment, reweigh, or care plan update as required by facility policy. The RD documented the weight loss more than two months later without recommending new interventions, and there was no evidence of prompt physician notification or care plan revision.
Staff failed to attempt or document non-pharmacological interventions before administering as-needed narcotic pain medication to a resident with lung cancer, and also gave the medication outside the prescribed pain level parameters, contrary to physician orders and facility policy.
An LPN was observed administering medications to two residents without following proper infection control practices. On several occasions, the LPN picked up tablets and capsules that had fallen onto the medication cart with bare hands and placed them into medication cups without performing hand hygiene or using gloves, contrary to facility policy.
A resident with end stage COPD and a history of falls did not receive timely and consistent implementation of planned fall prevention interventions, including post-catheter care, toileting schedules, and elimination tracking. Despite being identified as at risk for falls and having specific interventions in place, the resident experienced multiple falls, with documentation showing that key interventions were not effectively implemented or monitored.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of deep tissue injury. Despite physician orders for TruVue boots to prevent pressure sores, these were not included in the care plan or nurse aide Kardex. The resident was observed without the boots, and a nurse aide was unaware of the requirement due to its absence in the Kardex. The assistant DON confirmed the omission in the care plan.
The facility failed to ensure proper nursing practices for IV medication administration via PICC lines for three residents. LPNs, who were not authorized or trained, signed the MAR for administering medications through PICC lines. Interviews revealed LPNs were not educated on this task, and the DON confirmed that only RNs were allowed to administer medications through PICC lines, as per facility policy.
The facility failed to follow physician orders for PICC line management for two residents. Resident 270's PICC line care was not documented as performed weekly, and changes in catheter length were not reported to the physician. Similarly, Resident 105's PICC line care was not documented on multiple occasions. The Director of Nursing confirmed the lack of documentation and adherence to orders, resulting in a deficiency in nursing services.
The facility failed to securely store discontinued medications in three out of five medication storage rooms. Observations revealed that various medications were left unsecured in bins on countertops and floors. Staff interviews confirmed the medications were awaiting pharmacy pickup, but there was uncertainty about the pickup procedure. The DON acknowledged the need for timely return and secure storage of these medications.
A facility failed to update and implement a discharge plan for a resident with heart disease who wished to return to the community. Despite the resident's intact cognitive status and expressed desire for independent living, the discharge plan was not revised or acted upon, and there was no evidence of social services involvement in planning the transition.
The facility failed to follow physician orders for oxygen therapy and maintain sanitary conditions for respiratory equipment for two residents. One resident received less oxygen than prescribed, and another had uncovered nebulizer equipment on a cluttered nightstand. These issues were confirmed by staff interviews.
A facility failed to create a person-centered care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. This deficiency was confirmed by the DON, highlighting a lack of culturally competent, trauma-informed care.
The facility failed to maintain infection control practices, as observed with a resident's supra pubic catheter tubing on the floor, a soiled brief on a clean linen cart, and clean briefs and other supplies stored directly on the floor. The DON confirmed that equipment should be stored sanitarily.
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records for a resident. The resident had a physician order for Hydrocodone/Acetaminophen, but a review revealed discrepancies between the controlled substance records and medication administration records. The DON confirmed these inconsistencies.
A facility failed to develop and implement a care plan for a resident with a surgically implanted DRG stimulation therapy unit, used to manage chronic pain. Despite the resident's cognitive intactness and independence in daily activities, the care plan did not address the necessary management of the device during the resident's stay.
Failure to Accurately Assess and Prevent Pressure Injuries for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s pressure injury risk, implement appropriate preventive interventions, and conduct timely and thorough skin assessments, which contributed to the development of an unstageable pressure injury. Upon admission, the resident had multiple risk factors, including muscle weakness, difficulty walking, dependence on staff for bed mobility and transfers, incontinence, and moisture-associated skin issues. The admission nursing evaluation documented redness and rashes on the penis, groin, buttocks, sacrum, coccyx, and heel, but the clinical record did not include required details such as type of skin impairment, size, drainage, odor, or tissue characteristics, contrary to the facility’s wound management policy. Hospital records prior to admission had already identified moist, macerated skin with bleeding in the groin and penis area, blanchable redness on the coccyx, buttocks, and gluteal folds, and high risk for further skin breakdown, with specific recommendations for a low air loss bed, barrier products, avoidance of briefs, frequent repositioning, and use of a waffle cushion. The facility’s Braden Scale assessments were inconsistent with the resident’s documented functional status and known risk factors. On admission, staff scored the resident at low risk (Braden score 18), documenting no sensory impairment, the ability to move freely with minimal assistance, and only often moist skin, despite other records showing the resident required maximal assistance for bed mobility and transfers and could not independently reposition in bed or chair. A subsequent Braden assessment again scored the resident as low risk (score 16), indicating the resident could make occasional position changes without assistance and move freely with minimal help, even though therapy evaluations documented extensive to maximal assistance needs for sit-to-stand transfers, bed mobility, and transfers. Based on the resident’s actual condition and the presence of moisture-associated skin damage, the Braden categories for mobility, moisture, and activity should have reflected greater impairment, and a more accurate score would have placed the resident in a high-risk category. Progress notes later documented that the resident was at risk for skin breakdown due to moisture-associated skin areas, limited mobility, and incontinence, yet the interventions focused on educating the resident to reposition himself frequently, despite documentation that he was moderately cognitively impaired and unable to reposition without staff assistance. These notes did not reflect a change in approach to account for the resident’s dependence on staff. Eventually, a progress note documented the discovery of an unstageable pressure injury on the right gluteal area measuring 3 cm x 3 cm x 0.1 cm, with 100% purple, non-blanching tissue. At that time, the record referenced a low-air loss mattress order and continued two-hour repositioning, but prior to the development of this wound, the facility had not accurately assessed the resident’s pressure injury risk or fully implemented the recommended pressure-relieving and moisture-management interventions identified in the hospital records and required by facility policy. The facility’s own wound management/pressure reduction policy required comprehensive risk assessment using the Braden scale on admission and weekly for four weeks, weekly body checks by CNAs, and detailed documentation of any skin impairment, including location, size, description, drainage, odor, and necrosis. The policy also required specific actions when an unstageable pressure ulcer is identified, such as moist saline dressings, consultation with the wound nurse, physician, and dietician, and use of prevention or specialty mattresses as needed. In this case, the initial and subsequent Braden assessments did not reflect the resident’s true risk level, the admission skin findings were not documented in the detailed manner required, and the preventive interventions recommended by the hospital wound care provider were not fully implemented prior to the development of the unstageable pressure injury. These actions and omissions formed the basis of the cited deficiency under 28 Pa. Code 211.10(d) and 211.12(c)(d)(1)(3)(5).
Failure to Assess Catheter Necessity and Follow Post-Removal Protocols
Penalty
Summary
The facility failed to evaluate the clinical necessity of an indwelling urinary catheter and did not follow its own policies regarding catheter removal and bladder assessment for a resident. Upon admission, the resident, who had end stage COPD and was receiving hospice care, had a Foley catheter in place. The facility's policy required the use of an assessment tool to determine the need for an indwelling catheter and mandated physician notification if criteria were not met. However, there was no documented diagnosis or clinical justification for the continued use of the catheter in the clinical record, and the required assessment was not completed. The care plan indicated assistance with toileting, but there was no supporting documentation for a toileting plan or continence pattern. After the hospice nurse recommended discontinuing the Foley catheter, the physician was contacted and the catheter was removed. Despite facility policy requiring a bladder assessment and initiation of a voiding trial following catheter removal, there was no documentation that these steps were completed. Subsequently, the resident experienced three falls while attempting to get to the bathroom. A later bladder assessment noted mixed urinary continence and a toileting schedule, but there was no documented bladder tracker to support this plan. The DON confirmed the lack of documentation and acknowledged that facility policy was not followed.
Failure to Timely Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment and consistently monitor weights to identify and address significant weight loss for a resident with moderate calorie-protein malnutrition and dementia. According to facility policy, a weight change of 5% or more in one month requires a reweigh within 48 hours, reassessment by the dietitian, and care plan adjustments as needed. The resident experienced a 6.5% weight loss over a 33-day period, but there was no evidence of a timely reweigh, reassessment, or care plan revision following this significant change. The care plan, which already identified the resident as at risk for nutritional deficits, was not updated to reflect the new weight loss, and there was no documentation of physician notification or new interventions. Further review showed that the Registered Dietitian did not document the significant weight loss until over two months after it occurred, and at that time, no new interventions were recommended. The delay in identifying and responding to the resident's nutritional decline was inconsistent with the facility's policy and did not demonstrate timely reassessment or mitigation of nutritional risk. These findings were confirmed during an interview with the Nursing Home Administrator.
Failure to Follow Pain Management Protocols and Physician Orders
Penalty
Summary
Facility staff failed to follow established pain management protocols for a resident with a diagnosis of malignant neoplasm of the lung. The resident had a physician order for hydrocodone-acetaminophen to be administered as needed for moderate pain, specifically for pain levels rated between 5 and 7 on a numeric pain scale. However, clinical record review showed that staff administered the narcotic pain medication 19 times in June and 5 times in July without attempting or documenting non-pharmacological interventions prior to medication administration, as required by standard nursing practice and pain management guidelines. Additionally, the medication was administered outside the parameters of the physician's order on several occasions, including for pain levels categorized as severe, mild, or even when the resident reported no pain. These findings were confirmed through review of the Medication Administration Record and staff interviews, indicating that the facility did not ensure pain medications were administered according to physician orders and failed to consistently attempt or document non-pharmacological interventions prior to the use of as-needed narcotic pain medications.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
Staff failed to follow appropriate infection control practices during medication administration for two residents on the One North nursing unit. During the administration of medications, an LPN was observed picking up medications that had fallen onto the medication cart with his bare hands and placing them into the residents' medication cups without performing hand hygiene or wearing gloves. This occurred multiple times with different medications, including Vitamin D2, Senna, Lorazepam, and Furosemide, for two separate residents. A review of the facility's Infection Control Policy and Procedure indicated that standard precautions, including hand hygiene, are required to prevent healthcare-associated infections. Despite this, the LPN did not wash his hands or use gloves after handling medications that had come into contact with potentially contaminated surfaces. These findings were confirmed during an interview with the Nursing Home Administrator.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and monitor planned fall prevention interventions for a resident with end stage COPD who was receiving hospice services and had an indwelling Foley catheter. The resident was identified as being at risk for falls, and the care plan included maintaining a hazard-free environment, keeping the bed in the lowest locked position, ensuring the call bell and needed items were within reach, reinforcing call bell use, and using non-slip footwear. Despite these interventions, the resident experienced multiple falls. After the first fall, new interventions such as referrals to occupational and physical therapy and issuance of a reacher device were added. However, following the removal of the Foley catheter, nursing staff failed to complete a bladder assessment or initiate a voiding trial as recommended by the hospice nurse and physician. Subsequent falls occurred when the resident attempted to go to the bathroom without assistance, indicating that interventions such as offering toileting assistance and implementing a bowel and bladder tracker were either not documented or not effectively carried out. There was no evidence that the facility implemented or monitored the effectiveness of planned interventions, including toileting schedules, elimination tracking, and post-catheter care, to prevent repeated falls. The Director of Nursing confirmed that planned interventions were not timely implemented to prevent falls for this resident.
Failure to Implement Comprehensive Care Plan for Pressure Sore Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of deep tissue injury. The resident, who requires extensive assistance for activities of daily living and is at risk for pressure sores, was admitted with diagnoses including Down syndrome, seizure disorder, and severe intellectual disorder. Despite physician orders and previous interventions to prevent pressure injuries, such as the application of TruVue boots to the resident's heels, these interventions were not included in the resident's care plan or the nurse aide Kardex. During an observation, it was noted that the resident was not wearing the prescribed TruVue boots, which were found on the floor behind the bed. A nurse aide, unfamiliar with the resident's specific care needs, confirmed that the intervention was not listed in the Kardex she reviewed at the start of her shift. The assistant Director of Nursing acknowledged that the care plan did not include the necessary intervention for pressure sore prevention, as ordered by the physician, and there was no documented evidence of a care plan to prevent potential skin impairment.
Deficiency in IV Medication Administration via PICC Lines
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality as per the Pennsylvania Code Title 49, Professional and Vocational Standards. Specifically, the facility did not implement proper nursing practices for the administration of intravenous medication via central venous catheters for three residents. The deficiency was identified through clinical record reviews, facility policy reviews, and staff interviews. Resident 334, admitted with a PICC line for orthopedic aftercare and infection, had orders for Vancomycin administration via the PICC line. However, LPNs, who were not authorized or trained to administer medications through PICC lines, signed the Medication Administration Record (MAR) as having administered the medication. Similarly, Resident 105, admitted with a MRSA infection and a PICC line, had orders for Vancomycin, and multiple LPNs signed the MAR for administration. Resident 270, with osteomyelitis and a PICC line, had orders for Zosyn, and again, LPNs signed the MAR for administration. Interviews revealed that LPNs were not educated on administering medications through PICC lines and would call an RN to perform the task, yet still signed the MAR. The Director of Nursing confirmed that LPNs did not receive education on PICC line medication administration and that facility policy restricted this task to RNs. The facility lacked evidence of education or supervision regarding IV administration and PICC line usage for LPNs, leading to the deficiency.
Failure to Follow PICC Line Management Orders
Penalty
Summary
The facility failed to provide person-centered care and follow physician orders for the management of PICC lines for two residents. Resident 270, who was admitted with osteomyelitis and immunodeficiency, had a PICC line placed for IV antibiotic therapy. The facility's policy required weekly dressing changes and measurement of the external catheter length, with physician notification if migration occurred. However, there was no documented evidence that these procedures were performed weekly as ordered. The external catheter length changed from 0 cm to 2 cm and then to 1.5 cm, but the physician was not notified of these changes. Resident 105, who was readmitted with a right AKA, osteomyelitis, and sepsis, also had a PICC line. The physician ordered weekly dressing changes and external catheter length measurements. However, the Medication Administration Record (MAR) showed no documentation of these procedures being completed on several occasions. The facility could not provide evidence that the PICC line treatments and measurements were performed as ordered by the physician. Interviews with the Director of Nursing confirmed the lack of documentation and adherence to physician orders for both residents. The facility's failure to perform and document the required PICC line care and notify physicians of changes in catheter length constituted a deficiency in nursing services as per 28 Pa. Code 211.12 (c)(d)(1)(3)(5).
Failure to Securely Store Discontinued Medications
Penalty
Summary
The facility failed to store drugs and pharmacy supplies in a safe manner and did not remove medications awaiting final disposition in a timely manner across three out of five medication storage rooms. The facility's policy on the disposition of medications, last reviewed on July 24, 2024, requires that discontinued medications be marked and stored in a locked, secure area until they are destroyed or picked up by the pharmacy. However, observations revealed that discontinued medications were left unsecured in clear storage bins on countertops and floors in the first, second, and third-floor medication storage rooms. These bins contained various medications, including prescription medication cards, pill packages, nebulizer treatments, IV bags, and insulin pens. Interviews with staff members, including registered nurses and a licensed practical nurse, confirmed that the medications in the bins were discontinued and awaiting pharmacy pickup. The staff members were unsure of the procedure or frequency for pharmacy pickup. The Director of Nursing confirmed that the medications should have been returned to the pharmacy in a timely manner and stored securely to prevent unauthorized access and potential drug diversion. The facility's failure to adhere to its policy and ensure the secure storage of discontinued medications resulted in a deficiency under 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services and 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Implement Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 251, who was admitted with a diagnosis of heart disease. The resident, with an intact cognitive status as indicated by a BIMS score of 15, expressed a desire to return to the community and live independently. Despite this, the facility did not update the resident's discharge plan, which was initially noted on February 29, 2024, as requiring training and instruction for transitioning home. There was no documented evidence of social services working on the discharge plan or updating it with new goals and interventions to facilitate the resident's discharge to the community. This deficiency was confirmed by the Nursing Home Administrator during an interview on September 20, 2024.
Failure to Follow Oxygen Therapy Orders and Maintain Equipment Sanitation
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy and did not maintain oxygen equipment in a functional and sanitary manner for two residents. Resident 227, who was admitted with respiratory failure and required continuous supplemental oxygen, was observed on two occasions receiving only 2 liters per minute of oxygen instead of the prescribed 3 liters per minute. This discrepancy was confirmed by a licensed practical nurse during an observation. Resident 176, admitted with acute respiratory failure and pneumonia, had a physician's order for nebulizer treatment that ended on September 2, 2024. However, during an observation, the resident's nebulizer equipment was found uncovered and not bagged on a cluttered bedside nightstand, which included opened beverages and other personal items. The Director of Nursing confirmed that respiratory equipment should be bagged when not in use to prevent contamination, indicating a failure to maintain sanitary conditions for the equipment.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review, it was found that the resident's care plan did not identify symptoms or triggers related to PTSD, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the facility's inability to provide culturally competent, trauma-informed care in accordance with professional standards of practice. The resident was admitted with PTSD, a condition that requires careful management to promote emotional well-being and safety, which was not adequately addressed in the care plan.
Infection Control Deficiency in Resident Care Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed in several instances involving resident care equipment and supplies. Resident 337 was found with a supra pubic catheter and tubing lying directly on the floor, which poses a risk of contamination. Additionally, a soiled brief was observed on top of a clean linen cart, emitting a malodorous smell. In another room, seven clean briefs were placed directly on the floor next to a bedside table, and three heel lift boots were also found on the floor behind a bedside table. Furthermore, a box of tube feeding bottles and multiple boxes of briefs and bed pads were stored directly on the floor, with some boxes open and exposing the contents to the air. These observations were confirmed by the Director of Nursing, who acknowledged that resident care equipment should be stored in a sanitary manner.
Failure to Reconcile Controlled Drug Records
Penalty
Summary
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one resident. Resident 1, who was admitted with diagnoses including below the knee amputation and chronic lower back pain, had a physician order for Hydrocodone/Acetaminophen 5-325 mg to be administered as needed for pain. However, a review of the resident's controlled substance records and medication administration records for November and December 2023 revealed discrepancies. Nursing staff signed out doses of the controlled drug for administration on specific dates and times, but these doses were not documented as given to the resident in the medication administration records. During an interview, the Director of Nursing confirmed the inconsistencies between the controlled drug records and the medication administration records. This failure to properly document the administration of controlled substances indicates a lapse in the facility's pharmacy procedures and nursing services, as required by the relevant state codes.
Failure to Develop and Implement Care Plan for Pain Management Device
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a surgically implanted Dorsal Root Ganglion (DRG) stimulation therapy unit, which is used to manage chronic pain. The resident, who was admitted with diagnoses including below the knee amputation and chronic lower back pain, had a DRG stimulation unit that required specific care and services. Despite the resident being cognitively intact and independent in activities of daily living, the care plan did not address the management of the DRG stimulation unit or the necessary care associated with it during the resident's stay from November 22, 2023, to January 6, 2024, when the resident was discharged against medical advice (AMA). The deficiency was confirmed through a review of clinical records and an interview with the Nursing Home Administrator. The admission documentation and Minimum Data Set (MDS) assessments indicated the presence of the DRG stimulation unit, but the care plan failed to include any measures for its management. This oversight was identified during a survey conducted on July 30, 2024, highlighting the facility's failure to meet the resident's needs for pain control and device management.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
