Athens Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Athens, Pennsylvania.
- Location
- 200 South Main St, Athens, Pennsylvania 18810
- CMS Provider Number
- 396137
- Inspections on file
- 29
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Athens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not employ a full-time qualified dietitian and also lacked a qualified director of food and nutrition services, as the current dietary manager did not meet certification or educational requirements. This was confirmed through staff interviews and by the Nursing Home Administrator.
Surveyors observed unsanitary conditions in the main kitchen and two nursing units, including food debris and buildup in steam table wells, uncovered and undated milk cups in a cooler, dirty ceilings and light covers, porous wood shelving with stains, and soiled floors and equipment in pantries and refrigerators. These issues were identified during inspection and reviewed with the NHA and DON.
Staff used personal electronic devices to access and document resident medical records because there were not enough facility-supplied laptops and iPads available. This practice occurred during medication administration and routine care, despite staff having received training on HIPAA and confidentiality. The facility was unable to ensure the security and privacy of resident information as a result.
A resident with an Aspira catheter did not receive care as ordered by the physician, as only RN staff were authorized to perform drainage, dressing changes, and valve changes, but LPN staff completed these tasks on several occasions. Documentation was missing for required RN interventions, and only RNs received education on Aspira catheter care.
A resident's clinical record contained conflicting documentation regarding advance directives, with a physician's order for DNR status and a signed POLST indicating full code status. There was no evidence of updated documentation or discussions clarifying the resident's wishes for life-sustaining treatment.
Surveyors found that two residents' rooms had exposed drywall paper near the bathroom doors, partially covered by hand sanitizer dispensers. The hallway had a handrail with worn-off paint exposing metal, dried brown liquid splatter behind medication carts, and a vent above the nursing station with visible dust extending to ceiling tiles.
Two residents with orders for chair alarms to prevent falls were repeatedly observed in wheelchairs without the required alarms in place. Staff confirmed the absence of these alarms, despite care plans and physician orders specifying their use and regular checks.
A registered nurse did not follow Enhanced Barrier Precautions by failing to wear a gown during a chest tube dressing change for a resident with indwelling medical devices, despite an active order and posted signage requiring EBP. This action did not comply with CMS requirements for gown and glove use during high-contact care activities.
The facility did not notify the State Long-Term Care Ombudsman when several residents were transferred to the hospital following changes in their conditions. Clinical records showed that, despite hospital admissions, there was no documentation of the required notifications, and the administrator confirmed that such notifications were not being sent.
The facility did not include pharmacy or laboratory personnel in its infection control committee meetings, as required by the Act 52 Infection Control Plan. Attendance records for QAPI meetings showed no evidence of participation from these disciplines, despite regulatory requirements for a multidisciplinary committee.
Nurse aides were not properly evaluated for competency in essential care skills, including safe transfer techniques, as the facility relied solely on staff acknowledgment of training materials without requiring return demonstrations or direct observation. An LPN confirmed that this was the standard procedure for all nurse aides, and documentation for several aides lacked evidence of skill verification.
Two residents were involved in incidents where hazardous and illegal smoking materials, including marijuana, cigarettes, and a vape device, were present and used in their rooms. Despite LPNs and social services staff documenting these events and notifying supervisory staff, there was no evidence of investigation or remedial action by facility administration to address or remove the hazards.
The facility did not follow its own policies or CDC guidance for COVID-19 infection control, allowing two LPNs to return to work before meeting return-to-work criteria and failing to conduct contact tracing or testing for residents exposed to COVID-19. Several residents who were diagnosed with COVID-19 did not have appropriate transmission-based precautions initiated, and universal source control measures were not in place during the outbreak.
The facility failed to provide complete discharge summaries for two residents, lacking evidence of medication reconciliation and receipt by the residents or their responsible parties. Discharge documentation for one resident did not include medication reconciliation, while the other resident's summary lacked documentation of medication disposition.
The facility failed to ensure proper infection control for two residents with COVID-19, as signage for droplet precautions was inadequate and PPE usage was unclear. Observations showed that signs did not include necessary eye protection instructions, and staff used incorrect masks due to unclear guidance. Interviews confirmed these deficiencies, highlighting a failure to adhere to CDC guidelines.
The facility's main kitchen had multiple sanitation and food storage deficiencies, including dead insects in light covers, unlabeled and undated food items, and debris build-up on surfaces. The refrigerator and freezer had temperature issues and ice build-up, with no corrective actions documented. These findings were reviewed with the Dietary Manager, Nursing Home Administrator, and DON.
The facility failed to provide written notification of the state bed-hold policy to residents or their representatives during hospital transfers or therapeutic leave. This deficiency affected six residents, with no evidence of notification provided during multiple hospitalizations. The issue was confirmed during staff interviews and represents a recurring compliance problem with resident rights regulations.
The facility failed to ensure that pharmacy recommendations were addressed for four residents. For one resident, recommendations made by the pharmacist were not documented or acted upon, as confirmed by the DON. Another resident's record lacked documentation of multiple pharmacy recommendations, and the Administrator confirmed these findings. Additionally, a resident's record indicated recommendations were made, but there was no Clinical Pharmacy Report or documentation of actions taken by a physician.
The facility failed to maintain accurate clinical documentation for two residents. One resident's records incorrectly indicated ongoing hospice care despite discharge, while another resident's records erroneously included a discontinued medication. These errors were confirmed by facility staff.
The facility's arbitration agreements for several residents failed to ensure a neutral arbitration process, allowing the facility to select the arbitrator if parties could not agree within 30 days. This was confirmed by staff interviews and discussions with the administration.
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents with indwelling devices or wounds, as required by CMS guidelines. Observations showed a lack of PPE and signage in residents' rooms, and improper storage of a urinary collection bag. Staff interviews confirmed inadequate communication and implementation of EBP.
The facility failed to have a qualified Infection Preventionist after the previous Director of Nursing left. A licensed practical nurse took over the role without specialized training. The facility lacked evidence of infection control meetings and proper monitoring of infections and antibiotic use. The Director of Nursing was unaware of who managed the Pennsylvania Patient Safety Reporting System.
The facility did not offer updated COVID-19 vaccines to four residents, as required by CDC guidelines. The facility's policy lacked provisions for educating residents about the vaccine, and there was no documentation of vaccine administration. Interviews confirmed no evidence of education or vaccine offers to these residents.
Two residents in the facility did not receive proper pressure ulcer care as per physician's orders, with missed treatments documented over several months. One resident's wound was not assessed for weeks, and another resident's wound care was improperly conducted by an LPN. The DON confirmed these findings.
The facility failed to provide physician-ordered nutritional supplements to two residents at nutritional risk. One resident, with a history of skin breakdown, did not receive Boost as prescribed, leading to a small open area on the scrotum. Another resident, with an open wound, experienced significant weight loss due to the unavailability of Boost. Staff confirmed supply issues, acknowledging the deficiency.
The facility failed to maintain a clean and safe environment in the Ivy Nursing Unit and dining room. Observations revealed stains, debris, and maintenance issues in the dining room and shower room over two days. These findings were discussed with the Nursing Home Administrator and DON.
A resident with osteoarthritis and mobility issues did not receive the recommended restorative nursing program after discharge from physical therapy. The care plan required daily ambulation with assistance, but documentation showed the task was not completed on several occasions. Staff interviews revealed confusion about documentation and inconsistent implementation of the program.
A facility failed to provide adequate care for a resident with a PICC line and pacemaker. The facility lacked a policy for PICC line care, had no signage to prevent improper use of the resident's arm, and did not have emergency supplies available. The resident's care plan did not address their bacteremia, intravenous antibiotics, PICC line, or pacemaker. Observations confirmed the absence of necessary precautions and equipment for pacemaker monitoring.
A facility failed to coordinate dialysis services and administer morning medications for a resident who left for dialysis before breakfast. The resident's scheduled medications were not given on several dialysis days, and there was no documentation of coordination with the dialysis provider or physician to adjust the medication schedule. The DON confirmed these findings.
The facility failed to assess and obtain informed consent for bed rail use for two residents, leading to deficiencies. One resident with severe cognitive impairment had a right-sided enabler bar without reassessment or consent after room changes. Another resident had bilateral assistive devices without recent evaluation or consent after moving rooms. Staff confirmed the lack of reassessment and consent, violating facility policy.
The facility failed to ensure nursing staff had the necessary competencies for wound care, affecting four residents with skin concerns or wounds. The facility could not provide documentation of competencies for two LPNs, as confirmed by a clinical consultant. These findings were reviewed with the Administrator and DON.
The facility did not conduct annual performance evaluations for its nurse aides, as required. A review of active nurse aide staff revealed that three employees hired in 2022 had no documented evaluations. The clinical consultant confirmed the absence of performance evaluations for any current nurse aide.
The facility's main kitchen had a broken emergency release on the walk-in freezer, creating an entrapment risk. The issue was known to maintenance but remained unresolved. The Dietary Manager indicated that two staff members are required to prevent the door from fully closing. The Nursing Home Administrator was informed of the issue, and it was discussed with the Director of Nursing.
The facility failed to provide proper written notifications of hospital transfers to residents and their responsible parties, as well as to the Ombudsman, for six residents. The required components, such as contact information for the State long-term care appeal agency and the Ombudsman, were missing from the transfer notices. This deficiency was confirmed through clinical record reviews and staff interviews.
The facility failed to ensure that an LPN was trained and competent in administering IV medications through a PICC line for a resident with urosepsis, as required by Pennsylvania Code Title 49. The LPN administered Meropenem without documented evidence of necessary training or supervision.
Lack of Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an interview, the registered dietitian confirmed she was only employed at the facility three days a week and not on a full-time basis. At the same time, the dietary manager stated she did not possess certification as a dietary manager, food service manager, or any national certification for food service management and safety, nor did she hold a degree in food service management. Further confirmation from the Nursing Home Administrator established that the facility did not have a full-time qualified dietitian or a qualified director of food and nutrition services. The report does not mention any specific residents or their conditions in relation to this deficiency. The findings are based on staff interviews and direct confirmation from facility leadership.
Plan Of Correction
1. Facility is unable to retroactively correct past deficiency. 2. Employee #1 has been enrolled in the "ServeSafe for Managers" course. 3. Administrator will be educated on Qualified Dietary Staff Requirement. 4. Administrator/Designee will audit Employee #1's progress in "ServeSafe for Managers" course weekly x4 weeks to ensure timely completion. Results will be forwarded to QA committee. F 0801
Food Storage and Sanitation Deficiencies in Kitchen and Nursing Units
Penalty
Summary
The facility failed to maintain food service equipment and store food in a sanitary manner in the main kitchen and two nursing units, Sage and Ivy. Observations in the main kitchen revealed that the interior of the steam table water wells had a buildup of brown film and significant food debris, including vegetables and potatoes, floating in the water after breakfast service. In a two-door cooler, plastic bins containing cups of milk were found uncovered and undated. The ceiling over the dish room area had multiple rust-colored spots, a pipe near the ceiling was covered in visible dust, and the light covers were dirty with blackened areas and dried food splatter. The walk-in freezer had large chunks of ice on the floor behind the condenser, and the lower freezer shelves were lined with porous wood, which presented a risk for harboring bacteria. The dry storage area also had lower shelves lined with porous wood, some with dried liquid stains. On the Sage nursing unit, the pantry had a buildup of dust, debris, and dried spills on the floor, and a large garbage can with dried food splatter on its exterior. The wall behind and beside the garbage can was covered in dried food splatter from three feet up the wall to the floor. The refrigerator in the Sage pantry was soiled on the interior base and the lower vent unit was dusty and dirty. In the Ivy nursing unit pantry, the flooring was blackened and dirty, and the interior of a single door cooler had dried purple liquid on its base. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
All areas identified during survey regarding cleanliness were corrected. The uncovered cups of milk in the cooler were discarded at the time of the survey. The shelves have been replaced with a non-porous shelf. The lower shelves that were using wood were removed and replaced with a non-porous material. The floors of both pantries were cleaned. Food Service Director and Administrator will conduct an audit of general cleanliness standards of the kitchen to ensure no other cleanliness issues are present. Food Service Director and dietary staff will be educated on general cleanliness standards of the kitchen. Housekeeping, Dietary Staff, and Nursing will be educated on cleanliness of the pantries. Maintenance will be educated on cleaning the dust in the ceiling and kitchen ceilings will be added to a cleaning schedule. Daily cleaning checklists for each dietary shift will be updated, and dietary supervisor cleaning list was updated and will be signed off at the completion of shift. Weekly cleaning checklists will be implemented and signed off by FSD and submitted to the Admin. Nursing home administrator/designee will conduct random audits of kitchen areas daily x4 days a week for two weeks and then weekly times two months. Results will be reviewed during the monthly QAPI meeting to ensure ongoing compliance.
Failure to Protect Resident Privacy Due to Use of Personal Electronic Devices
Penalty
Summary
Staff at the facility failed to ensure the privacy and confidentiality of resident medical records by allowing the use of personal electronic devices to access and document resident information. During medication administration, an LPN was observed using her own personal device to access a resident's medical record, citing a lack of available facility-supplied devices as the reason. The LPN confirmed that she brought her own device from home to ensure timely access to resident records for medication administration and documentation. Further observations and staff interviews revealed that other staff members, including nurse aides, also brought personal electronic devices into the facility for the purpose of accessing and documenting in resident records. At the time of the survey, there were not enough facility-supplied laptops and iPads available for the number of staff on duty, leading to the use of personal devices. Facility documentation confirmed that staff had received training on HIPAA, confidentiality, and resident rights, which included the requirement to keep resident information private. Despite this training, the facility was unable to ensure the security of resident personal and private information due to the use of personal devices for accessing clinical records. The lack of sufficient facility-supplied electronic devices directly contributed to this deficiency, as staff resorted to using their own devices to fulfill their duties. The facility's inability to provide adequate equipment resulted in a failure to protect resident privacy and confidentiality as required by federal and state regulations.
Plan Of Correction
1. Facility is unable to retroactively correct staff members using personal computers for documentation purposes. 2. Staff were provided additional facility-issued laptops/POC documentation devices. 3. Administrator checked the status of laptops previously ordered and expected delivery date. Additional laptops were also purchased; unused facility laptops/desktops were provided to nursing units. All nursing staff will be re-educated on HIPAA/only using facility-provided computer equipment. 4. Random audits will be conducted to ensure only facility-issued computers are being used, 2x a day, 3x a week, then weekly for 4 weeks. Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI meetings for review and to ensure ongoing compliance. F 0583
Failure to Follow Physician Orders for Aspira Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered interventions and treatments for a resident with an Aspira catheter were carried out according to professional standards and the care plan. Physician orders specified that only RN staff were to drain the Aspira catheter every other day on day shift, not to exceed 1000 ml per session, and to document the output, color, and character of the drainage. Additionally, only RN staff were to change the catheter dressing every other day and the connecting valve weekly. However, clinical record review revealed multiple dates where there was no documentation that RN staff performed these tasks. Instead, LPN staff documented completion of the catheter drainage and dressing changes on several occasions, contrary to the physician's orders. Further review showed that only RN staff received education on the management of Aspira catheters, with no documentation of similar education for LPN staff. The lack of proper documentation and adherence to physician orders was confirmed during an interview with the Director of Nursing. These findings indicate that the facility did not provide care in accordance with the prescribed orders and professional standards for the resident with the Aspira catheter.
Plan Of Correction
1. Resident 67 has discharged from the facility. 2. An audit of the last 14 days was completed of any other Aspira Catheter Drains or chest tubes in the facility, and it was confirmed that LPNs were not providing valve changes or dressing changes. 3. All LPN staff will be educated, and competency will be completed related to Chest Tubes and Chest Tube Management. All licensed staff will be educated on proper documentation in the electronic medical record. 4. Audits will be conducted by the DON/Designee of any resident with a chest tube to ensure all physician orders related to the same are being followed for dressing changes and documentation. These audits will occur four times a week daily, weekly for four weeks, and monthly for two months. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.
Failure to Maintain Consistent Advance Directives
Penalty
Summary
The facility failed to establish clear and consistent advance directives for one resident. Clinical record review showed that the resident had a physician's order dated May 28, 2025, indicating a DNR (do not resuscitate) status, meaning no CPR should be performed if the resident had no pulse and was not breathing. However, a POLST (Pennsylvania Orders for Life Sustaining Treatment) form dated May 7, 2025, and signed by the resident, indicated that the resident desired to be a full code, meaning CPR should be attempted under the same circumstances. There was no documented evidence that the resident completed an updated POLST after May 7, 2025, nor was there any documentation of discussions with facility staff or the physician indicating a change in the resident's wishes regarding life-sustaining treatment. This lack of documentation and clarity regarding the resident's advance directives was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Resident 28's Advanced Directive was immediately clarified with resident and signed by MD. Information was updated in resident orders, special instructions, and Care Plan. Resident 28's Advanced Directive was uploaded into electronic medical record. 2. An audit of all residents' POLST was completed to ensure resident order, special instructions, and Care Plan matched wishes expressed on signed POLST form. 3. All new or amended POLST forms will have an order immediately entered in PCC. Care Plan and special instructions will be updated. Any new/amended POLST will be uploaded to the "Document" tab in residents' electronic medical chart. All Licensed Staff will be educated on immediately entering/amending order, special instructions, and Care Plan based on POLST form. All existing resident POLST will be uploaded into residents' electronic record. 4. Audits will be conducted of any admissions or updated POLST, daily 4x a week, weekly for 4 weeks, and monthly x2 by the Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI meetings for review and to ensure ongoing compliance.
Failure to Maintain Clean and Homelike Environment on Nursing Unit
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment on one of its nursing units. Specifically, in the rooms of two residents, there was visible damage to the walls next to the bathroom doors, with 10 to 12 inches and 2 inches of exposed drywall paper, respectively. In both cases, a hand sanitizer dispenser was installed, partially covering the damaged areas. Additionally, the hallway on the same unit had a painted handrail with the paint worn off, exposing the underlying metal, particularly at the intersection near the nursing station. Further observations included dried brown liquid splatter on the lower portion of the wall behind two medication carts across from the nursing station, and a vent above the nursing station with visible dust hanging on both the interior and exterior, extending to the surrounding ceiling tiles. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Any dried liquid observed on the lower portion of the wall behind Med Carts was cleaned the day of survey. The vent above Sage Nursing Station was cleaned the day of survey. Resident 27's and Resident 66's wall next to the bathroom door has been fixed, under the hand sanitizer dispenser. The handrails have been painted on Sage Hallway. 2. A whole house room audit was completed to identify any other resident rooms that drywall is exposed. A whole house audit was also completed to ensure no vents had a buildup of dust, and no walls had dried liquid present. 3. Areas that drywall is exposed will be fixed, vents and walls will be cleaned to ensure a clean, home-like environment. Housekeeping and Nursing staff will be educated to ensure walls are clean. Maintenance Staff will be educated on fixing exposed drywall, painting hand rails when metal is exposed and maintaining clean vents. 4. Environmental audits will be conducted of the Sage Hallway/Nursing Station, daily 4x a week, weekly for 4 weeks and monthly x2 by the Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement required fall prevention interventions for two residents who were assessed as being at risk for falls. For one resident with diagnoses including unsteadiness, dementia, gait abnormalities, and muscle weakness, clinical records and care plans indicated the need for a chair alarm to be in place and checked every shift. Despite this, observations on multiple occasions revealed that the resident was mobile in a wheelchair without the chair alarm attached, as it was found hanging on the dresser instead. Staff confirmed that the alarm should have been in use and subsequently placed it on the wheelchair after being notified. For another resident, a physician's order required the use of a chair alarm and regular checks for its placement and function. However, repeated observations showed the resident seated in a wheelchair without the alarm in place. Staff interviews confirmed the absence of the alarm during these times. These failures to follow physician orders and care plan interventions for fall prevention were confirmed through staff interviews and review of clinical documentation.
Plan Of Correction
1. Resident 7 and 46 immediately had a chair alarm added the day of the survey. 2. A whole house audit was completed on all residents who are ordered/CP'ed to have a chair alarm to ensure placement in wheelchair, and that the chair alarm is listed in Kardex. 3. All residents who have an order/or CP'ed as a fall intervention will have a chair alarm in place when in a wheelchair. All nursing staff will be educated to ensure the chair alarm is in place when the resident is in a chair. All CNAs will be educated to check Kardex if a chair alarm is needed for safety. 4. Random resident audits will be conducted of residents requiring a chair alarm, daily 4x a week, weekly for 4 weeks, and monthly x2 by the Administrator/designee to ensure the chair alarm is in place and in working order. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.
Failure to Implement Enhanced Barrier Precautions During High-Contact Procedure
Penalty
Summary
A deficiency was identified when a registered nurse failed to implement Enhanced Barrier Precautions (EBP) during a high-contact procedure for a resident with indwelling medical devices. Specifically, during a chest tube dressing change, the nurse donned gloves but did not wear a gown as required by EBP protocols. The resident had both a urinary Foley catheter and a chest tube, and there was an active physician's order for EBP due to these devices. An enhanced barrier sign was posted outside the resident's room, indicating the need for these precautions. The observation was made during a dressing change, where the nurse removed the old dressing, cleansed the area, changed gloves, and applied a new dressing without donning a gown. The failure to use a gown during this high-contact activity was contrary to the requirements outlined in the CMS memo on EBP, which mandates gown and glove use for residents with indwelling devices during such procedures. The deficiency was confirmed through observation, clinical record review, and staff interviews.
Plan Of Correction
1. Facility is unable to retroactively correct staff member entering room to give high-contact care with incorrect PPE. 2. An audit of all residents on EBP was completed to ensure proper signage to include proper PPE required. 3. All nursing staff will be educated on EBP, including what PPE is required and when it is required. 4. Administrator or designee will complete a random audit of residents on EBP 4x a week for 4 weeks and weekly for 2 months to ensure proper PPE is being used and at the correct times. Results will be reviewed by QAPI committee for further action planning as necessary.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman upon the transfer of multiple residents to the hospital. Clinical record reviews for several residents revealed that, following changes in their conditions, they were transferred and admitted to the hospital. However, there was no documentation that the required written notification was provided to the State Ombudsman regarding these transfers. This deficiency was identified for nine out of ten residents reviewed for hospitalizations. Specific examples include residents who were sent to the hospital due to chest pain, changes in condition, or for re-evaluation, with subsequent documentation confirming their admission to the hospital. Despite these transfers, the records lacked evidence that the Ombudsman was notified as required by federal regulations. Interviews with the Nursing Home Administrator confirmed that notifications to the Ombudsman were not being sent for hospital admissions. The surveyor reviewed these findings with the Nursing Home Administrator, who acknowledged that the facility did not send notifications for hospital admissions. The lack of documentation and notification was consistent across multiple cases, indicating a systemic failure to comply with the regulatory requirement to inform the State Ombudsman of resident transfers to the hospital.
Plan Of Correction
1. The State Long Term Care Ombudsman will be notified via email of the transfers of Residents 13, 23, 26, 28, 50, 55, 57, 64, and 66. 2. NHA/designee will audit the facility-initiated transfers for the last 30 days to ensure that the Office of the State Long-Term Care Ombudsman was notified. 3. Social Service Director/designee will maintain a log of residents transferred from the facility. Monthly, the NHA/designee will audit the log to ensure compliance, and SSD will submit the log to the Office of the State Long-Term Care Ombudsman. The date of notification will be recorded on the audit form. 4. All hospital transfers will be reviewed in AM meeting 4x a week for 4 weeks, and weekly x2 months to ensure written notification was provided to the State Long Term Care Ombudsman. Results of the audits will be presented at the Quality Assurance Performance Improvement meetings for review and to ensure ongoing compliance.
Failure to Include Required Disciplines in Infection Control Committee
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements outlined in the Act 52 Infection Control Plan. Specifically, the facility did not include representatives from pharmacy or laboratory personnel in its infection control committee meetings, as required by regulation. Documentation provided by the facility, titled "QAPI (Quality Assurance and Performance Improvement) Attendance," was reviewed for several meeting dates, but there was no evidence or signatures indicating that pharmacy or lab staff attended any of these meetings. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that infection control meetings were held during QAPI meetings on a quarterly basis or more frequently if needed. However, attendance records for these meetings did not show participation from pharmacy or laboratory personnel, which is a required component of the multidisciplinary infection control committee. No information about specific residents or their medical conditions was included in the report.
Plan Of Correction
1. Facility is unable to retroactively correct deficiency for past Act 52 meetings. 2. An employee of the Pharmacy and a Representative from the Laboratory have been invited to the next QA/Act 52 meeting. 3. All attempts will be made to ensure all appropriate members are present and will facilitate via phone conference if necessary. The Administrator and DON will be educated on which members of the multidisciplinary committee need to be present for QA/Act 52 meetings. 4. Monthly sign-in sheets for QA/Act 52 will be reviewed to ensure all appropriate members of QA/Act 52 meeting was present monthly and results will be forwarded to QA meeting to ensure ongoing compliance.
Failure to Verify Nurse Aide Competency in Resident Care Skills
Penalty
Summary
The facility failed to ensure that nurse aide staff possessed and demonstrated the specific competencies and skill sets required for safe resident care, particularly regarding transfer techniques. Documentation review for three nurse aides showed that while staff completed and signed off on various competency worksheets and attended in-service education, there was no evidence that the facility evaluated their knowledge or skills through return demonstrations or direct observation. In one case, a nurse aide's record lacked the required CNA Competencies worksheet, and in another, the documentation did not include attestation by another staff member confirming the aide's demonstration of skills. For a newly hired aide, orientation records indicated only acknowledgment of training topics, without any verification of competency through demonstration. Interviews with the LPN responsible for nurse aide competency training revealed that the process consisted of providing information packets and obtaining staff signatures to confirm they had read the material. There were no return demonstrations or practical evaluations to verify competency in physical skills for any nurse aide. This approach was confirmed to be standard practice for all nurse aides employed by the facility, as discussed with the Nursing Home Administrator and the Director of Nursing.
Failure to Investigate and Address Smoking Hazards
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for two residents, as evidenced by multiple documented incidents involving the presence and use of potentially hazardous and illegal smoking materials. For one resident, nursing documentation twice noted a strong smell of marijuana in the resident's room, with the resident admitting to using marijuana for pain relief. Despite these observations and notifications to supervisory staff, there was no evidence in the clinical record that the facility administration investigated these incidents or took further action to address the presence of illegal substances. Additionally, another resident was found with a vape device and was later caught smoking a cigarette in her room, with a lighter also present. Social services documentation confirmed the resident admitted to receiving a cigarette from another resident. Despite staff awareness and documentation of these events, there was no evidence that the facility conducted an investigation, obtained staff witness statements, or implemented interventions such as room searches to remove hazardous smoking materials. Interviews with facility leadership confirmed their awareness of these incidents and the lack of follow-up investigation or remedial action.
Failure to Implement COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices related to COVID-19, resulting in deficiencies in work exclusions for staff, contact tracing for residents, and the application of transmission-based precautions (TBP). Specifically, two employees who tested positive for COVID-19 returned to work before meeting the facility’s own policy requirements for return-to-work criteria, including the absence of two negative antigen tests. Both employees provided direct care to residents during their infectious periods, and there was no evidence that residents potentially exposed by these staff members were tested for COVID-19 as required by CDC guidance. Additionally, the facility did not conduct contact tracing for residents who were diagnosed with COVID-19, including those who had received aerosol-generating procedures or had close contact with other residents and staff. For example, residents who were hospitalized with COVID-19 or pneumonia did not have their close contacts identified or tested, and there was no documentation of universal source control measures, such as mandatory mask use, being in place during the outbreak. The facility also failed to implement TBP for residents who returned from the hospital with a recent COVID-19 diagnosis or who tested positive while in the facility, with delays or lack of documentation regarding the initiation of appropriate isolation precautions. Interviews with facility leadership confirmed these lapses, including the absence of contact tracing, lack of universal masking, and failure to follow both facility policy and CDC recommendations for testing and isolation. The report also notes that multiple residents and staff across two nursing units tested positive for COVID-19 within a short period, yet the facility did not initiate broad-based testing or enhanced precautions as outlined in national guidance. These actions and inactions directly contributed to the cited deficiencies in infection prevention and control.
Failure to Provide Complete Discharge Summaries
Penalty
Summary
The facility failed to provide a discharge summary with the necessary components for two residents, CR1 and CR2, upon their planned discharge. For Resident CR1, the nursing documentation indicated that the resident was discharged to home with home health services on July 10, 2024. However, the electronic discharge summary did not show evidence that the resident or her responsible party received the document, nor did it include a reconciliation of all medications with the resident. Similarly, for Resident CR2, the nursing documentation noted that arrangements were made for home health and infusion therapy to assist with wound treatment and continuous antibiotic infusion at home. The discharge summary reviewed with Resident CR2 included future appointments but lacked documentation of the disposition or reconciliation of medications. There was no evidence that the resident or her responsible party received the discharge summary, and it did not include a reconciliation of all medications. The facility confirmed during an interview that there was no evidence of discharge instructions, including medication reconciliation, being provided to the residents or their responsible parties.
Inadequate COVID-19 Precaution Signage and PPE Usage
Penalty
Summary
The facility failed to maintain an environment free from the potential spread of infection for two residents who were under COVID-19 transmission-based precautions. The facility's policy on infection prevention and control measures, last reviewed on August 1, 2023, was supposed to follow CDC guidelines to prevent COVID-19 transmission. However, observations revealed that the signage for droplet precautions was inadequate, as it did not include necessary instructions for eye protection and was improperly modified by writing 'Droplet' over 'Contact' on the signs. Resident 1 and Resident 3 were both isolated due to positive COVID-19 tests, with Resident 1's positive status communicated to his nephew on July 31, 2024, and Resident 3 testing positive on July 29, 2024. Observations on August 1, 2024, showed that the signage on their doorways did not meet the requirements for droplet precautions, lacking instructions for eye protection. The PPE organizers at their doors contained gowns, gloves, surgical masks, and N95 masks, but the signage did not specify which type of mask was required. Interviews with staff confirmed the deficiencies in the signage and PPE usage. Employee 3, a registered nurse, acknowledged that the signage did not include necessary droplet precaution measures. Employee 2, a nurse aide, admitted to using a surgical mask instead of an N95 mask while caring for Resident 1, due to unclear instructions on the signage. The surveyor discussed these concerns with the Nursing Home Administrator and a clinical consultant, highlighting the facility's failure to adhere to proper infection control protocols.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food items and maintain equipment in a safe and sanitary manner in the main kitchen. During an initial tour, multiple deficiencies were observed, including dead insects and debris in ceiling light covers, opened bread products without open dates, and a build-up of debris on storage racks and at the kitchen perimeter. The steamer exhaust area had a significant dust build-up, and a container identified as clean had a dead insect inside. Additionally, a coffee container was broken, and plastic cups were stained with debris in their storage container. Unlabeled and undated food items, such as cereals, bread, and brown sugar-like substances, were found, and there was an accumulation of debris on various kitchen surfaces. Further observations revealed issues with the refrigerator and freezer, including unlabeled and undated food items, dislodged lids on fruit containers, and a significant ice build-up in the freezer due to a bowed door. The facility's temperature log indicated refrigerator temperatures above the desired level on several dates, with no documented corrective actions. The loading dock area also had cobwebs, debris, and dust accumulation. These findings were reviewed with the Dietary Manager, Nursing Home Administrator, and Director of Nursing.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the state bed-hold policy to residents or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for six out of seven residents reviewed for hospitalization concerns. For Resident 3, there was no evidence of written notification provided during hospitalizations on April 3, 2024, and May 10, 2024. Similarly, Resident 19 was transferred to the emergency room on April 15, 2024, without written notification to her representative. Resident 34 also did not receive written notification during transfers on April 7, 2024, and April 20, 2024. Resident 60's hospitalization on February 8, 2024, and May 17, 2024, also lacked the required notification. Additionally, the facility could not provide the necessary documentation for Residents 37 and 59 during their respective hospitalizations. The surveyor confirmed these findings during interviews with the Director of Nursing, the Nursing Home Administrator, and other staff members. The deficiency was previously cited on July 21, 2023, indicating a recurring issue with the facility's compliance with the regulation 483.15(d) Notice of Bed Hold Policy Before/Upon Transfer. The lack of documentation and communication regarding the bed-hold policy represents a failure to uphold resident rights as outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.29(f).
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician addressed pharmacy recommendations for four out of five residents reviewed. For Resident 10, the pharmacist made recommendations on two occasions, but there was no documented evidence in the clinical record to indicate what the recommendations were or if they were acted upon. The Director of Nursing (DON) confirmed that the recommendations could not be located. Similarly, for Resident 46, the pharmacist made recommendations on multiple dates, but again, there was no documentation in the clinical record to show what the recommendations were or if they were acted upon, as confirmed by the DON. Resident 25's clinical record also lacked documentation of pharmacy recommendations made on three separate dates, and the Administrator confirmed these findings. For Resident 22, the clinical record indicated that recommendations were made by the consultant pharmacist, but there was no Clinical Pharmacy Report or documentation of the details of the recommendation or any action taken by a physician. Despite a request for additional information during an interview with the Nursing Home Administrator, the DON, and another employee, the facility did not provide further documentation during the onsite survey.
Inaccurate Clinical Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate clinical documentation for two residents, leading to discrepancies in their medical records. For Resident 20, the clinical records inaccurately indicated that the resident was still receiving hospice care, despite being discharged from hospice services on March 17, 2023. This error persisted in multiple physician's progress notes dated from March 21, 2023, to May 16, 2024, which continued to mention hospice care and treatment plans related to hospice, even though the resident was no longer under such care. The Nursing Home Administrator and Director of Nursing confirmed these documentation errors during an interview. For Resident 50, the facility failed to update the medication orders accurately following the resident's hospitalization from April 30, 2024, to May 7, 2024. The resident's gabapentin prescription was discontinued on May 1, 2024, but subsequent clinical documentation erroneously included gabapentin as part of the resident's pain management plan. This error was confirmed by the Director of Nursing, who acknowledged that there was no current order for gabapentin in the electronic medical record, indicating a documentation error.
Deficient Arbitration Agreements Compromise Neutrality
Penalty
Summary
The facility's arbitration agreements were found to be deficient in ensuring a neutral and fair arbitration process for six residents who had signed these agreements. The agreements allowed the facility to select the arbitrator initially or if the parties could not agree on a neutral arbitration service within 30 days. This was evident in the agreements signed by Residents 34, 47, 16, 62, 49, and 26, where the facility retained the power to choose the arbitrator, potentially compromising the neutrality of the arbitration process. Interviews with facility staff, including Employee 13 from medical records, confirmed that the arbitration agreements for the mentioned residents allowed the facility to select the arbitrator. This was further corroborated during a discussion with the Nursing Home Administrator, the Director of Nursing, and a clinical consultant. The deficiency was identified under the Pennsylvania Code sections related to the responsibility of the licensee, management, and resident rights.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions (EBP) for four residents, as required by the CMS memo released on March 20, 2024. The memo mandates the use of EBP, including gown and glove use, for residents with chronic wounds or indwelling medical devices during high-contact care activities. Observations and clinical record reviews revealed that Residents 25 and 49, both with indwelling urinary catheters, did not have documented evidence of EBP implementation, nor was there any signage or PPE present in their rooms to indicate such precautions. Similarly, Resident 59, who had a Stage 4 pressure ulcer, also lacked documentation and visible evidence of EBP in her room. Additionally, Resident 60, who had an indwelling urinary catheter and a pressure ulcer, was observed with her urinary collection bag stored directly on the floor, and the dignity bag meant to hold the collection bag was empty. Although a PPE organizer was present, there were no bins for discarding PPE before leaving the room. Interviews with staff, including a nurse aide and a licensed practical nurse, confirmed the lack of communication and implementation of EBP for these residents. The Director of Nursing and the Administrator acknowledged these deficiencies during the surveyor's review.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. The previous Director of Nursing, who held the position of Infection Preventionist, left the facility on June 2, 2024. Following her departure, a licensed practical nurse assumed the role without having completed any specialized training in infection prevention and control. Interviews with the Nursing Home Administrator confirmed that no current staff members had the necessary qualifications or training for the role. Additionally, the facility was unable to provide evidence of infection control committee meetings since the last standard survey in July 2023. The Director of Nursing admitted to attempting to monitor antibiotic use and infection prevalence but could not provide a current line listing of infections or evidence of antibiotic surveillance. Furthermore, she did not have access to the Pennsylvania Patient Safety Reporting System and was unaware of who was responsible for this task. These findings were confirmed in a joint interview with the Director of Nursing, the Nursing Home Administrator, and a clinical consultant.
Failure to Offer COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to four out of five residents reviewed for immunization concerns, as per the guidelines set by the Centers for Disease Control (CDC). The facility's policy on COVID-19 infection prevention and control measures, last reviewed on August 1, 2023, did not include provisions for educating residents about the benefits and risks of the COVID-19 vaccine, nor did it document the education provided or the administration of vaccines. Clinical record reviews revealed that Residents 2, 35, 36, and 60 had not been offered the updated 2023-2024 COVID-19 vaccines, despite their last immunizations being dated back to 2021 or 2022. Interviews with the Director of Nursing, the Nursing Home Administrator, and a clinical consultant confirmed that there was no additional evidence to show that these residents were provided with education or the opportunity to receive the updated COVID-19 vaccines. This lack of action was in violation of the facility's own policies and the CDC's recommendations, as well as state regulations regarding medical records and resident care policies.
Failure in Pressure Ulcer Care and Infection Prevention
Penalty
Summary
The facility failed to provide adequate treatment and services to promote healing and prevent infections for pressure ulcers in two residents. Resident 58 had a physician's order for wound care on her coccyx, which was not consistently followed by the nursing staff. The Treatment Administration Record (TAR) showed missed treatments on several occasions in March 2024, and there was no documented evidence of wound assessment or measurement until a wound consultant evaluated it in late April 2024. The wound was assessed as a Stage 4 pressure ulcer, indicating severe tissue loss. Additionally, there was no documentation of assessments for several weeks in April 2024. Resident 59 also experienced lapses in wound care as per physician's orders. The TAR indicated missed treatments in March, April, and May 2024. An observation in June 2024 revealed improper wound care technique by an LPN, who failed to change gloves and wash hands between handling supplies and applying a clean dressing. This was confirmed by an interview with the Director of Nursing, highlighting the facility's failure to adhere to proper wound care protocols.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional interventions for two residents identified as being at nutritional risk. Resident 25's care plan indicated the need for a nutritional supplement, Boost, to maintain skin integrity. Despite a physician's order to provide 8 oz of Boost twice daily, the Medication Administration Record (MAR) for April and May 2024 showed multiple instances where the supplement was not administered due to it being unavailable or on order. This lack of administration coincided with the development of a small open area on Resident 25's scrotum, as noted in nursing documentation. Similarly, Resident 59, who had an open wound, was ordered to receive Boost twice daily before meals. However, the MAR for April and May 2024 documented numerous occasions where the supplement was not given due to unavailability. This resident experienced a significant weight loss of 9 percent in one month, as noted in a dietary report. Interviews with facility staff confirmed that the supply of Boost was not consistently received as ordered, acknowledging the deficiency in providing necessary nutritional support.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment in the Ivy Nursing Unit and a dining room, as observed during a survey. In the dining room adjacent to the main kitchen, surveyors noted various stains on the floor, debris in the protective covers of overhead lights, stained and cracked ceiling tiles, dust and debris on windowsills, and dried splash stains on the windows. These observations were made on two consecutive days, indicating a lack of adequate housekeeping and maintenance services. In the shower room, surveyors observed a scratched and stained commode seat, chipped paint, dead insects in the ceiling light cover, debris under the shower gurney cushion, cobwebs in an opening in the brick wall, discarded linens on the sink, and debris in the shower drain. These conditions were consistent over two days, with additional linens found on the second day. The findings were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide a homelike environment as required by regulations.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to complete a restorative nursing program for a resident with osteoarthritis, abnormalities of gait and mobility, and muscle weakness. The resident's care plan required assistance with walking and transferring, with a goal to ambulate up to 70 feet with a rolling walker and one-assist daily. The physical therapy discharge summary recommended a restorative nursing program with a good prognosis, contingent on consistent staff follow-through. However, documentation revealed that the restorative task was not completed on several occasions, with specific dates in May and June marked as not applicable. Interviews with facility staff revealed a lack of clarity and follow-through regarding the restorative program. The Director of Therapy was unsure about the meaning of 'Not Applicable' in the documentation, while a nurse aide indicated that she marked 'Not Applicable' when she did not observe the resident completing the program during her shift. This lack of consistent implementation and documentation of the restorative nursing program led to the deficiency, as the facility did not adhere to the recommended therapy discharge plan for the resident.
Deficiency in PICC Line and Pacemaker Care
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with a PICC line and an implanted pacemaker. The surveyor found that the facility did not have a policy or procedure for PICC line care, and there was no signage or information to prevent the use of the resident's right arm for blood pressure readings or venipunctures. Additionally, there were no emergency supplies available in the resident's room in case of complications with the PICC line. The clinical record review revealed that there was no care plan developed for the resident's bacteremia diagnosis, intravenous antibiotic administration, PICC line use, or pacemaker care. The resident was admitted with a diagnosis of bacteremia and required intravenous antibiotics for six weeks. The resident also had a surgical history of pacemaker implantation. Observations showed that the PICC line site was clean and dry, but there were no precautions in place to protect the arm with the PICC line. Interviews with staff confirmed the lack of signage and emergency supplies. The facility did not have a care plan addressing the resident's medical needs, and the necessary equipment for pacemaker monitoring was not initially available in the resident's room.
Failure to Coordinate Dialysis and Medication Administration
Penalty
Summary
The facility failed to coordinate dialysis services and administer physician-ordered medications for a resident who required dialysis. The resident, who underwent kidney dialysis on Tuesdays, Thursdays, and Saturdays at an outside provider, left the facility before breakfast at approximately 6:45 AM. The resident's physician orders included morning medications such as Miralax, Protonix, Eliquis, and Simethicone, which were scheduled to be administered at 7:00 AM and 8:00 AM. However, the Medication Administration Record for June 2024 showed that these medications were not administered on several days when the resident was at dialysis. There was no documentation indicating that the facility coordinated with the dialysis provider or the resident's physician to adjust the medication schedule or determine if skipping the medications was appropriate. The Director of Nursing confirmed these findings.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bed rails for two residents, leading to deficiencies in their care. For Resident 10, the facility did not reassess the bed rails or obtain informed consent when the resident changed rooms multiple times. The resident, who had severe cognitive impairment and a history of cerebrovascular accident, was observed with a right-sided enabler bar, but documentation showed that bilateral bed rails were initially assessed. The facility did not provide evidence of reassessment or informed consent for the current bed setup. Similarly, for Resident 34, the facility did not reassess the bed rails or obtain informed consent after the resident moved rooms twice. The resident had enabler bars installed on the right side of the bed, but later observations showed assistive devices mounted bilaterally. The facility's documentation did not include a recent bed rail evaluation or consent for the bilateral use of enabler devices, despite changes in the resident's room and bed setup. Interviews with facility staff, including the Nursing Home Administrator and Maintenance Director, confirmed the lack of reassessment and informed consent for both residents. The facility's failure to follow its policy on bed rail use and obtain necessary documentation contributed to the deficiencies identified by the surveyors.
Lack of Nursing Competency in Wound Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to wound care. This deficiency was identified through a review of the facility's current resident population documentation, which revealed that four residents had skin concerns and/or wounds. Upon request, the facility was unable to provide any documentation of nursing staff competencies for wound care. An interview with the clinical consultant confirmed that the facility did not have any competencies on file for two licensed practical nurses involved in wound care. These findings were discussed with the Administrator and Director of Nursing.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of every nurse aide at least once every 12 months, as required by regulations. This deficiency was identified during a review of the facility's list of active nurse aide staff, which included three employees hired in 2022. Upon request, there was no documented evidence of performance evaluations for these employees. An interview with the clinical consultant confirmed that no performance evaluations could be provided for any current nurse aide working in the facility.
Broken Emergency Release in Walk-In Freezer
Penalty
Summary
The facility failed to ensure that essential equipment in the main kitchen was in safe operating condition. During an observation and interview with the Dietary Manager, it was discovered that the emergency release on the interior of the walk-in freezer was broken, posing an entrapment risk if the door were to close and lock with a staff member inside. It was unclear how long the emergency release had been non-functional. The Dietary Manager noted that two staff members are required to be present when using the walk-in freezer to prevent the door from fully closing. Although maintenance was aware of the issue, it had not been addressed. The Nursing Home Administrator was informed of the problem on two occasions on the same day, and it was further discussed in a meeting with the Nursing Home Administrator and Director of Nursing two days later.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide proper written notification of transfer to residents and their responsible parties, as well as to the Office of the State Long-Term Care Ombudsman, for six out of seven residents reviewed. This deficiency was identified through clinical record reviews and staff interviews. The residents involved were transferred to the hospital without receiving a transfer notice that included all required components, such as contact information for the State long-term care appeal agency and the Ombudsman. Resident 37 was transferred to the hospital without documented evidence of a proper transfer notice being provided to him or his responsible party, nor was the Ombudsman notified. Similarly, Resident 59 was transferred without the necessary notifications. The facility's administrator confirmed these findings during an interview. Resident 3 was admitted to the hospital on two occasions, and in both instances, the facility failed to provide the required transfer notice components to her or her responsible party, and the Ombudsman was not notified. Additional residents, including Residents 19, 34, and 60, were also transferred to the hospital without receiving the necessary written notifications. The facility did not provide evidence of notifying the Ombudsman for these transfers either. The Director of Nursing, Nursing Home Administrator, and another employee confirmed these findings during an interview with the surveyor.
Failure to Ensure Competency in IV Medication Administration
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not verifying that a licensed practical nurse (LPN) was knowledgeable and competent in administering intravenous (IV) medications through a peripherally inserted central catheter (PICC) for a resident. The Pennsylvania Code Title 49, Professional and Vocational Standards, requires that LPNs perform IV therapy functions only if they possess the necessary knowledge, skill, and ability, and under appropriate supervision. The clinical record review revealed that the LPN administered Meropenem, an antibiotic, intravenously to the resident on multiple occasions without documented evidence of training, supervision, or competency assessment for this procedure. The resident had an order for Meropenem IV solution to be administered twice daily for urosepsis. Despite this, the facility could not provide documentation that the LPN had received the required training or supervision to safely administer the medication through the PICC line. This deficiency was confirmed through an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of documentation for the LPN's competency in this area.
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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