Artman Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ambler, Pennsylvania.
- Location
- 250 North Bethlehem Pike, Ambler, Pennsylvania 19002
- CMS Provider Number
- 395922
- Inspections on file
- 18
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Artman Lutheran Home during CMS and state inspections, most recent first.
A resident's individualized care plan required the use of a functioning chair alarm to alert staff of unassisted rising. However, the chair alarm was not connected properly, resulting in the resident being found on the floor after a fall. The DON confirmed the alarm was not in place as specified in the care plan, and the deficiency was identified through review of records and staff interviews.
A resident received a pneumococcal vaccine without documented screening for contraindications or precautions, as required by facility policy and CDC guidelines. The infection preventionist confirmed that screening was not completed prior to vaccine administration.
Surveyors found that multiple residents were unaware of their right to file grievances anonymously, and there was no clearly designated area or box for submitting anonymous grievances, despite facility policy and posted notices indicating this right. The only available box was labeled as a suggestion box, and residents did not recognize it as a means to file anonymous grievances.
A resident with cardiac conditions sustained burn injuries after spilling coffee on herself in bed. The incident was not immediately reported to the State Survey Agency as required by facility policy and state regulations, constituting a failure to report suspected neglect.
A resident with cardiac conditions suffered burns after spilling coffee, and the facility did not obtain required written witness statements from involved staff, resulting in an incomplete investigation into the alleged neglect.
The facility administered COVID-19 vaccines to multiple residents without completing the required pre-vaccination screenings for contraindications or precautions, as mandated by CDC guidelines and facility policy. This was confirmed by documentation review and staff interview.
A resident with heart failure and atrial fibrillation was found on the floor with a head hematoma after a broken bed rail failed to lock in place. The facility did not have a scheduled maintenance program for bed rails, checking them only when preparing rooms for new admissions, contrary to its policy requiring regular assessments.
The facility failed to provide education on the benefits and side effects of influenza immunization to two residents, as required by their policy. The Director of Nursing confirmed that consent forms are given only upon admission, and there was no documented evidence of education being provided before offering the vaccine.
A facility failed to create a comprehensive care plan for a resident with impaired skin integrity. The resident, who had memory issues and was at risk for pressure ulcers, developed a deep tissue injury on the right fifth toe. Despite facility policy requiring a care plan within seven days of the MDS assessment, no plan was documented to address the resident's skin condition.
A dietary aide in an LTC facility failed to follow the policy for reheating food, serving a resident with cognitive impairment and dementia a hot dog and beans without checking the temperature or allowing it to cool. The facility's policy required food to be stirred or rotated and allowed to stand covered for two minutes to ensure it was under 180°F, but this procedure was not followed.
A resident with a physician order for nectar consistency liquids was provided with regular consistency orange juice, contrary to their dietary needs. This was confirmed by a nurse aide during an observation.
The facility failed to designate a qualified infection preventionist to oversee the infection prevention and control program. The Director of Nursing, who was also the infection preventionist, lacked documented evidence of part-time work in this role, leading to non-compliance with the program's requirements.
The facility failed to provide appropriate ADL assistance for two residents. A resident with moderate cognitive impairment did not receive scheduled showers on multiple occasions, as confirmed by the DON. Another resident, who prefers bed baths due to a colostomy bag, was observed with poor personal hygiene and expressed a desire for grooming assistance, which was not provided. This failure violated resident rights and nursing services regulations.
A facility failed to follow physician orders for a resident, including a toileting schedule and the use of tubi-grips, leading to care deficiencies. Documentation showed missed toileting attempts, and observations confirmed the absence of tubi-grips. Additionally, broken wheelchair footrest loops were noted for two residents, with initial reports suggesting they were unnecessary, indicating lapses in care and equipment maintenance.
Failure to Implement Care Plan Intervention for Chair Alarm
Penalty
Summary
The facility failed to implement a care plan intervention for a resident by not ensuring the proper use of a chair alarm as specified in the individualized care plan. The care plan, dated September 5, 2025, required the use of an electronic chair alarm to alert staff of unassisted rising, with instructions to ensure the device was in place every shift. On October 7, 2025, the resident was found on the floor in their room, with the fall investigation revealing that the chair alarm was not connected properly at the time of the incident. The resident's fall prevention measures included bed and chair alarms, hourly checks due to poor safety awareness and fall risk, nonskid socks while in bed, and staff supervision in the bathroom. The Director of Nursing confirmed that the chair alarm was not connected as required by the care plan when the fall occurred. The deficiency was identified through a review of clinical records, the facility's fall investigation, and staff interviews, which established that the intervention to provide a properly functioning chair alarm was not implemented as directed in the resident's care plan.
Failure to Screen Resident Prior to Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that pneumococcal immunization was provided according to professional standards of practice for one resident. Facility policy states that all residents will be offered the pneumococcal vaccine per CDC recommendations and that effective screening for contraindications and precautions must be completed prior to vaccine administration. Documentation review showed that a resident received the pneumococcal vaccine, but there was no evidence in the clinical record of completed screening prior to immunization. An interview with the infection preventionist confirmed that the facility does not complete screening for pneumococcal immunizations before administration.
Failure to Ensure Residents' Right to File Anonymous Grievances
Penalty
Summary
Surveyors determined that the facility failed to ensure residents were aware of and able to file grievances anonymously, as required by facility policy and resident rights regulations. During interviews with nine alert and oriented residents, all stated they were not aware of their right to file grievances anonymously. Observations revealed that, although a sign indicated residents could file grievances anonymously, there was no clearly designated area for submitting anonymous grievances, and the only available box was labeled as a suggestion box. The facility's policy referenced locked boxes for anonymous grievances, but these were not observed to be in place or clearly identified for this purpose at the time of the survey.
Failure to Report Suspected Neglect Following Resident Burn Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one resident. According to facility policy, any suspected or alleged abuse must be reported to the Department of Health, and investigations should include witness interviews and signed statements. However, for one resident with a history of heart failure and atrial fibrillation, this protocol was not followed after an incident involving a burn injury. The incident involved a resident who spilled coffee on herself while in bed, resulting in scattered intact blisters on her right abdominal area, under her right breast, and upper right thigh. The resident did not immediately report the injury to nursing staff, and when the incident was discovered, the Director of Nursing confirmed that it was not reported to the State Survey Agency as required by policy and regulation. This omission constituted a failure to report suspected neglect in accordance with state requirements.
Failure to Complete Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of possible neglect involving a resident with heart failure and atrial fibrillation. The resident reported spilling coffee on herself, and upon assessment, was found to have scattered intact blisters on her right abdominal area, under her right breast, and upper right thigh. Although the facility's policy requires obtaining written witness statements as part of the investigation process, the facility did not secure these statements from the dining coordinator who placed the coffee on the tray or the aide who served the coffee. This omission resulted in an incomplete investigation into the incident, as required by facility policy and state regulations.
Failure to Complete Required Screening Prior to COVID-19 Vaccination
Penalty
Summary
The facility failed to provide COVID-19 immunizations according to professional standards of practice for 35 out of 73 residents reviewed. Facility policy required that all residents, staff, and volunteers be offered the COVID-19 vaccine per CDC recommendations, and that vaccines be administered by qualified personnel under standing orders. CDC guidelines specify that effective screening for contraindications and precautions must be completed before administering any vaccine dose. Documentation review showed that multiple residents received COVID-19 immunizations on various dates. However, there was no evidence in the clinical records that screenings were completed prior to the administration of the vaccines for these residents. The absence of completed screenings meant that the facility did not determine whether residents had any medical contraindications or precautions before immunization, as required by both facility policy and federal regulations. An interview with the facility's infection preventionist confirmed that screenings were not completed for the listed residents prior to their COVID-19 immunizations. This failure to follow established procedures and professional standards resulted in a deficiency under the cited regulation.
Failure to Regularly Inspect and Maintain Bed Rails
Penalty
Summary
The facility failed to implement a scheduled maintenance program for bed rails as required by its own policy, which states that individual bed rail assessments and evaluations should be performed regularly. A resident with a history of heart failure and atrial fibrillation was admitted and later experienced an incident where they were found on the floor with a hematoma to the left side of the head. Nursing documentation revealed that the right-side bed rail was broken and would not lock in place at the time of the incident. The Director of Maintenance confirmed that prior to the incident, bed rails were only checked when preparing a room for a new admission, and not on a regular schedule.
Failure to Educate Residents on Influenza Immunization
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of influenza immunization to two residents, R29 and R14, as required by their policy. The facility's policy mandates that each resident should be protected against the influenza virus, with the vaccine offered annually. The policy also requires that if a resident or their representative declines the vaccine, education about the risks and complications of not receiving it should be discussed. However, upon review of the clinical records for Residents R29 and R14, there was no documented evidence that they received the necessary education before being offered the influenza immunization. An interview with the Director of Nursing, Employee E2, revealed that consent forms for vaccinations are provided only upon admission, and residents are verbally asked if they want the vaccines at the beginning of each flu season. Employee E2 confirmed that there was no documented evidence of education being provided to the residents or their representatives regarding the benefits and potential side effects of the influenza immunization. This lack of documentation and education constitutes a deficiency in the facility's adherence to its vaccination policy.
Failure to Develop Comprehensive Care Plan for Skin Integrity
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident identified as R26, who had impaired skin integrity. The facility's policy requires that a care plan be developed for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychosocial needs. This care plan should be developed within seven days of the submission of the complete Minimum Data Set (MDS) assessment. However, upon review of Resident R26's quarterly MDS, it was noted that the resident had short and long-term memory problems and was at risk of developing pressure ulcers. Despite this, the facility did not document a care plan addressing the resident's impaired skin integrity, even after a skilled wound report indicated the presence of a deep tissue injury on the resident's right fifth toe, with an onset date of July 11, 2024.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The facility failed to implement procedures to ensure food was served at safe, appetizing temperatures for a resident observed in the dining room. The facility's policy on food temperatures, which was undated, stated that microwave reheating is appropriate when a resident requests it, and the food should be stirred or rotated and allowed to stand covered for two minutes to ensure the temperature is under 180 degrees Fahrenheit. However, during an observation, a dietary aide heated a plate of food for a resident with moderate cognitive impairment and diagnoses of muscle weakness and dementia. The dietary aide handed the plate directly to a nurse aide without checking the temperature or allowing it to sit, as required by the policy. This was confirmed in an interview with the dietary aide, who acknowledged that the temperature was not checked to ensure it was safe.
Failure to Provide Nectar Consistency Liquids
Penalty
Summary
The facility failed to provide beverages consistent with the needs of a resident, identified as Resident R17, who required altered fluid consistency. A review of Resident R17's clinical record showed a physician order dated August 18, 2024, specifying that the resident was to receive nectar consistency liquids. However, during an observation on August 21, 2024, at 10:00 a.m., it was noted that Resident R17's breakfast tray included orange juice of a thin, regular consistency, contrary to the nectar thick liquids indicated on the meal ticket. This discrepancy was confirmed in an interview with Nurse Aide, Employee E3, who acknowledged that the wrong beverage was provided to Resident R17.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program. The facility's Infection Control Program Overview outlines the goals and responsibilities for infection control, including the need for a designated infection control practitioner. However, the facility did not have a designated individual working at least part-time as an infection preventionist, as required by the program. The Director of Nursing, Employee E2, was identified as the infection preventionist, but there was no documented evidence of her working part-time in this role. Interviews with Employee E2 revealed that she was the full-time Director of Nursing and the only employee with an infection control certification. Despite her dual role, there was no documentation to support her part-time work as an infection preventionist. This lack of documentation and formal designation led to the deficiency, as the facility did not comply with the requirement to have a designated infection preventionist working at least part-time.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide appropriate assistance with Activities of Daily Living (ADL) for two residents who were unable to perform these tasks independently. Resident R1, who has a moderately impaired cognitive status with a BIMS score of 8, was dependent on staff for showers, transfers, and toileting. Despite being scheduled for showers on Wednesdays and Saturdays, Resident R1 did not receive showers on several Wednesdays in May and June 2024, as confirmed by the Director of Nursing. Resident R3, who prefers bed baths due to having a colostomy bag, was observed with unkempt personal hygiene, including mid-size facial hair, long greasy hair with white flakes, and long nails. Resident R3 expressed a desire to have their hair, facial hair, and nails trimmed but was unable to do so independently. This observation was confirmed by a Licensed Nurse, Employee E5. The facility's failure to provide scheduled showers and personal grooming assistance violated resident rights and nursing services regulations.
Failure to Follow Physician Orders and Maintain Equipment
Penalty
Summary
The facility failed to adhere to physician orders for a resident, leading to deficiencies in care. The orders included a specific toileting schedule, the use of tubi-grips on the resident's lower extremities, and the placement of a gel cushion on the resident's wheelchair. However, documentation revealed that the 11:00 a.m. toileting attempt was not recorded on numerous dates, and observations confirmed that the resident was not taken to the bathroom as scheduled. Additionally, during an observation, it was noted that the resident was not wearing tubi-grips as ordered, and the responsible nurse admitted to forgetting and discovered that none were available, indicating a lapse in following the prescribed care plan. Further observations highlighted issues with the resident's wheelchair, as the footrest heel loops were broken, which could affect the resident's safety and comfort. Another resident at the same dining table also had a broken footrest loop. The Rehabilitation Director replaced the broken parts but initially reported that the loops were unnecessary. These findings demonstrate a failure to implement and maintain physician-ordered care and equipment checks, compromising the quality of care provided to the resident.
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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