Aventura At Creekside
Inspection history, citations, penalties and survey trends for this long-term care facility in Carbondale, Pennsylvania.
- Location
- 45 North Scott Street, Carbondale, Pennsylvania 18407
- CMS Provider Number
- 395984
- Inspections on file
- 35
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 27 (2 serious)
Citation history
Health deficiencies cited at Aventura At Creekside during CMS and state inspections, most recent first.
The facility did not obtain food from approved sources or ensure that food was stored, prepared, distributed, and served according to professional standards, resulting in a deficiency related to food safety and handling.
The facility did not maintain an effective pest control program, as evidenced by the presence of live and dead cockroaches in the kitchen and food preparation areas. Staff and management confirmed ongoing pest sightings, and pest control services were not provided at the increased frequency requested. Documentation of pest monitoring was lacking, and a pest control inspection identified active infestations and structural vulnerabilities.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any person.
Surveyors identified unsanitary conditions in the dietary department, including dirty meal carts stored near food prep areas, soiled ceiling tiles and light fixtures, a sticky and contaminated juice dispenser, and improper storage of wire racks and debris in the dry storage area. These findings indicated a failure to maintain food storage, preparation, and service areas in a clean and sanitary condition as required by facility policy and federal guidelines.
Three residents with chronic respiratory conditions did not receive supplemental oxygen at the flow rates ordered by their physicians. Observations found that oxygen concentrators were set below the prescribed levels, and staff confirmed the discrepancies. The facility's policy requires licensed nurses to administer and monitor oxygen therapy as ordered, but this was not followed for these residents.
Surveyors found that multi-dose insulin pens, including Insulin Degludec, Insulin Glargine, and Insulin Aspart, were opened and in use without proper labeling of the date opened, and one pen was used past its expiration date. An LPN and the DON confirmed these practices did not follow facility policy or manufacturer guidelines.
Facility administration failed to immediately remove a nurse aide accused of physical abuse from resident contact, and did not report or investigate additional abuse allegations involving two other residents and two nurse aides. These failures resulted in Immediate Jeopardy and placed all residents at risk.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with Parkinson's Disease experienced significant unplanned weight loss, and the facility failed to document the provision of recommended nutritional interventions, notify the physician and representative, or conduct timely follow-up assessments and monitoring as required.
Nursing staff did not consistently follow procedures for verifying and documenting controlled substance counts at shift change on two medication carts. Facility policy requires both oncoming and outgoing nurses to count and sign off on controlled medications at each shift change, but multiple instances were found where the oncoming nurse failed to sign the narcotic count sheets. Interviews confirmed staff awareness of the policy, and the administrator acknowledged the lack of consistent implementation.
A resident with intact cognition and a history of frequent falls and pneumonia experienced a monthly rate increase without receiving the required advance written notice. The facility's admission agreement mandated a 60-day written notification for financial changes, but billing records and staff interviews confirmed that neither the resident nor his representative was notified before the higher charges were applied.
The facility did not post its smoking policy in required areas, failed to provide fire safety equipment in the designated smoking patio, and did not assess a cognitively intact resident with nicotine dependence for safe smoking practices. Staff confirmed these lapses, and documentation showed the resident became agitated and verbally aggressive when denied access to smoke without assessment.
A resident with multiple medical conditions, who was cognitively intact, expressed a desire to transfer to a local facility that allowed smoking. Despite this, the resident was discharged to a facility several hours away without documentation explaining why local options were not pursued or why the resident's preferences were not honored. The facility also lacked documentation confirming guardianship status and did not demonstrate that the resident was involved in the discharge decision-making process.
Three residents experienced harm due to the facility's failure to provide adequate supervision, staff training, and individualized interventions to prevent accidents. One resident with severe cognitive impairment suffered multiple falls, including a head injury after being left unsupervised and another fall from a Broda chair transported by untrained staff. Another resident with dementia and Parkinson's disease had repeated falls and injuries due to insufficient care planning and lack of staff guidance. A third resident, at risk for wandering, exited the building unsupervised when the lobby was left unattended, resulting in an elopement event.
A resident, who was cognitively intact and responsible for his own care, experienced a daily room rate increase without receiving advance written notice. Billing records and facility documentation confirmed that neither the resident nor his representative was notified of the rate change before it took effect, and the NHA acknowledged the notice was not sent in a timely manner.
The facility failed to maintain sanitary food storage and service practices, risking food-borne illness for all residents. Observations included a sticky kitchen floor, buildup in juice machines, undated and uncovered food items, improper ice machine drainage, and expired food. The janitor's closet was cluttered, and dirty garbage cans were noted. These issues were confirmed by the Nursing Home Administrator.
A resident with contractures in both ankles and elbows did not receive prescribed therapeutic devices, including contracture boots and elbow splints, as required. Documentation showed multiple instances in August and September where these devices were not applied or removed as scheduled. Observations confirmed the absence of these devices, and staff interviews revealed unfamiliarity with the resident's care needs.
The facility failed to assess and manage bowel and bladder function for four residents, including a resident who became frequently incontinent without a new toileting plan, and another who did not receive a two-hour check and change program. Additionally, a resident with a catheter experienced inadequate care, with their catheter bag not emptied regularly, leading to excessive urine accumulation. These deficiencies were confirmed by staff and the Nursing Home Administrator.
The facility did not ensure monthly drug regimen reviews by a licensed pharmacist for two residents with dementia-related diagnoses. This was confirmed by the DON, who acknowledged the lack of documentation for the required reviews.
The facility did not follow the planned menus for residents on a pureed diet. During a lunch meal service, it was observed that essential items like pureed mixed vegetables and sugar cookies were missing from the tray line. An interview with the District Kitchen Manager confirmed the oversight, highlighting a failure to adhere to dietary service regulations.
The facility failed to serve meals at safe and palatable temperatures for a resident. Lunch trays were delayed, sitting for about 40 minutes before being delivered. A test tray showed food temperatures below the safe range, with a cheeseburger at 90°F, fries at 82°F, and coleslaw at 65°F. The District Kitchen Manager confirmed the deficiency.
The facility failed to accommodate meal preferences for four residents. During lunch, two residents did not receive the requested pasta salad, one did not receive fruit cocktail, and another was served a plain cheeseburger instead of a barbecue cheeseburger. The Nursing Home Administrator confirmed the dietary staff's failure to meet these preferences.
The facility failed to secure resident medical records, as observed on multiple occasions. A copier room in the front lobby was found unlocked and open, containing unsecured resident medical records accessible to non-medical staff. Additionally, an unlocked shed outside the facility contained a box of papers with resident medical records, also unsecured. An interview with the Nursing Home Administrator confirmed the facility's failure to maintain organized and secured resident medical records.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them, despite having a policy in place. During a survey, it was observed that no EBP were in use for residents with conditions such as tube feeding, foley catheters, and open wounds. The Director of Nursing confirmed the lack of EBP implementation, violating both facility policy and CMS/CDC guidance.
The facility failed to maintain essential equipment in a safe condition, with resident items stored in unsanitary conditions. Mattresses, bed bolsters, and air mattresses were placed directly on dirty floors, and wheelchairs had dirty wheels. An interview with the NHA confirmed the facility's failure to ensure safe equipment conditions.
The facility failed to maintain an effective pest control program, as small flies were observed around the juice machine in the food and nutrition services department. The pest control contract did not cover flies, and invoices from June to September did not show treatment for them. The NHA confirmed the lack of evidence for an effective program, noting a recent contract with a new pest management company.
The facility failed to ensure timely responses to resident requests, as reported by several residents who experienced delays exceeding 30 minutes, leading to soiling themselves. Despite raising these concerns in resident council meetings, no resolution was documented. The NHA and DON acknowledged the issue but could not explain the delays.
The facility failed to maintain a clean and safe environment, as observed in the main dining room and a resident's bathroom. Debris, food particles, and sticky floors were noted, along with dirty place settings and a resident breakfast tray left from meal service. A hole in a resident's bathroom wall was covered with plaster, and the floor was dirty with debris. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to develop comprehensive care plans for a resident with depression and two residents who smoke. One resident's care plan did not address his preference for bedtime, leading to frustration and agitation. The other two residents, identified as smokers, had no mention of smoking in their care plans. The Nursing Home Administrator and DON confirmed these deficiencies.
A facility failed to update and implement an individualized discharge plan for a resident with bipolar disorder, despite the resident having intact cognition. The resident's care plan, identifying them as a long-term placement, was not revised since December of the previous year, and there was no evidence of discussions about discharge plans in social service notes. The Nursing Home Administrator confirmed this oversight.
A resident with diabetes and muscle weakness experienced an unwitnessed fall. An LPN assessed the resident, noting no injuries and starting neuro checks, but there was no documented RN assessment as required by professional standards. The Nursing Home Administrator confirmed this deficiency.
A resident with a history of falls and high fall risk did not receive effective interventions to prevent further falls. Despite multiple falls, the facility failed to update the resident's care plan with new interventions for nearly two months. Observations showed the resident's call bell was out of reach, and alarms were not effectively preventing falls. Staff confirmed the facility's responsibility to implement the care plan.
A resident with Parkinson's disease had a nebulizer machine that was not properly maintained, with visible dirt and dried substances on the equipment. Despite multiple observations, the equipment remained unclean, and the facility's Director of Nursing confirmed the failure to maintain the nebulizer equipment according to policy.
A facility failed to consistently attempt non-pharmacological interventions before administering narcotic pain medication to a resident with neuropathy and hypertension. The resident's MARs for July, September, and October 2024 showed multiple instances where oxycodone was given without prior non-pharmacological attempts. Interviews confirmed the lack of evidence for such attempts before administering the medication.
A facility failed to ensure accurate accounting of controlled drugs for a resident discharged home. The facility's policy requires drug disposition records to be forwarded to medical records and a complete list of medications provided upon discharge. However, there was no record of the disposition of the resident's Alprazolam 0.5 mg. The NHA had no further information and expected compliance with the policy.
A resident received Ativan without proper documentation of behaviors or attempts at non-pharmacological interventions. The facility failed to monitor behaviors and potential adverse consequences of psychoactive drug use, as confirmed by the DON.
The facility failed to follow procedures for storing multi-dose medications, as observed when a registered nurse was present. Open vials of Lidocaine Hydrochloride Injection USP and Tuberculin Purified Protein Derivative were found undated and uninitialed, contrary to the facility's policy. Interviews with the Nursing Home Administrator and DON confirmed the non-compliance with storage and use by date requirements.
The facility failed to implement non-pharmacological interventions before administering psychotropic anti-anxiety medication to a resident. Despite having a plan of correction, the facility did not document attempts of non-pharmacological interventions for a resident who received multiple doses of Alprazolam, as confirmed by the DON.
A facility failed to communicate necessary resident information to a receiving health care provider during a transfer. Essential details such as advance directives, special instructions, and care plan goals were not documented or conveyed, as confirmed by the DON and NHA.
A facility failed to provide a written notice of an emergency hospital transfer for a resident. The clinical record lacked documentation of the required notice, which should have included details such as the reason for transfer, effective date, and contact information for the Ombudsman. The Nursing Home Administrator confirmed the absence of these notifications.
A facility failed to provide a resident or their representative with written notification of the bed-hold policy upon hospital transfer. A review of records and staff interviews revealed that the resident was transferred to the hospital and returned without documented evidence of receiving the bed-hold policy information. The DON confirmed the lack of documentation.
A resident with severe cognitive impairment was admitted to the facility with a Healthcare Directive indicating DNR and do not hospitalize. The directive was not uploaded to the electronic record until three days post-admission. An agency nurse failed to note the resident's code status, leading to the resident being sent to the hospital when found unresponsive, contrary to their wishes.
A resident with severe cognitive impairment lost one of their hearing aids, and the facility failed to assist in replacing it. Despite the resident's daughter filing a grievance and planning an insurance claim, the facility did not help in locating resources or arranging appointments and transportation for a replacement. Interviews confirmed no plans were made to assist in securing a new device.
The facility failed to maintain sanitary food storage and handling practices, increasing the risk of food-borne illness. Observations included a damaged refrigerator, unlabeled shakes, and unsanitary handling by a cook. Meal trays were also worn, inhibiting proper cleaning.
The facility failed to provide timely care, as residents reported long wait times for assistance, particularly during night shifts and meal times. Grievances and Resident Council meeting minutes highlighted issues with insufficient staffing and untimely responses to call bells. Interviews with residents confirmed ongoing problems, with one resident waiting two hours for help. The Nursing Home Administrator acknowledged the issue but could not explain the delays.
The facility failed to maintain resident dignity during meal service, leaving two residents waiting for assistance while others ate. Staff used foul language within earshot of residents, and two residents were observed with undignified personal appearances, including wearing fall risk bracelets that should have been removed. These issues were confirmed by the DON and NHA.
The facility failed to maintain a clean and orderly environment, with observations of debris, stains, and dirt in various areas, including resident rooms and common areas. A resident expressed dissatisfaction with the cleaning, noting persistent dirt and stained bathroom floors. The NHA confirmed the expectation for cleanliness, highlighting a deficiency in maintaining standards.
The facility failed to maintain a safe and homelike environment, with uneven flooring, missing floor molding, and cluttered shower rooms. Residents reported unfinished construction, and potential electrical hazards were observed, indicating inadequate quality assurance monitoring.
A resident in an LTC facility experienced an unwitnessed fall and showed signs of confusion and jaundice. Despite a nurse aide reporting these symptoms to the RN Supervisor, there was no documented prompt assessment of the resident's condition before the fall. The Director of Nursing confirmed the lack of timely assessment, indicating a deficiency in nursing services.
The facility failed to consistently monitor the weights of two residents, leading to significant unplanned weight loss. Despite recommendations for weekly weight checks, the facility did not adhere to its guidelines, resulting in inadequate monitoring of the residents' nutritional status. The DON confirmed this oversight.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Effective Pest Control Program in Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy and regulatory standards. Despite having a policy that mandates ongoing pest control and contracted services, observations in the kitchen revealed the presence of both dead and live cockroaches, particularly in the food preparation and dishwasher areas. Staff interviews confirmed sightings of cockroaches and water bugs, and the food service director acknowledged that the administrator had been informed of the issue about a month prior. Although the facility requested an increase in pest control service frequency from monthly to every two weeks, records showed that the pest control company did not provide service as scheduled during one of the biweekly intervals. Additionally, pest control reports documented heavy treatment for roaches, but the interval between services did not align with the requested schedule. Further investigation revealed that the facility lacked documentation of ongoing monitoring for cockroach activity, as required by policy. The maintenance director was unable to provide evidence of monitoring or identification of potential entry points and hiding places for pests. A licensed pest control inspector's inspection confirmed active cockroach infestations around kitchen walls, behind appliances, and under the dishwasher, and identified structural vulnerabilities such as gaps around pipes and the need for door sweeps. The nursing home administrator confirmed the facility's failure to maintain an effective pest control program and acknowledged the responsibility to keep the facility free of pests.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's dietary department during an initial tour. Dirty breakfast meal carts with soiled resident trays were stored near food preparation areas, clean utensils, and cooking equipment. Ceiling tiles and light fixtures above the dishwashing machine were found with brown discoloration, splattered residue, and visible dirt and debris inside the light covers throughout the kitchen. The juice station's thickened juice dispenser contained a gelatinous substance inside the nozzle and was sticky to the touch, with staff reporting that cleaning was performed only weekly. Further inspection of the dry storage area revealed wire racks stored directly on the floor, debris under shelving, and an accumulation of dirt and debris behind the door. These findings were reviewed with the Nursing Home Administrator, who acknowledged the requirement for the dietary department to be maintained in a clean and sanitary condition. The facility's policies and federal guidelines require all food storage, preparation, and service areas to be kept clean and sanitary, but these standards were not met as evidenced by the observed conditions.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician orders for three residents with chronic respiratory conditions. For one resident with chronic respiratory failure and hypoxia, the physician ordered continuous supplemental oxygen at 4 liters per minute (LPM) via nasal cannula. However, observation revealed the oxygen concentrator was set at 0 LPM while the resident was awake and upright, and the Director of Nursing confirmed the resident should have been receiving oxygen as ordered. Another resident with chronic obstructive pulmonary disease (COPD) had a physician's order for continuous oxygen at 3 LPM, but was observed with the flowmeter set at 2.5 LPM; this was confirmed by an LPN. A third resident, also with COPD, was prescribed continuous oxygen at 3 LPM but was observed with the concentrator set at 2 LPM, and the resident reported not feeling oxygen from the cannula, though not in distress. The DON confirmed the setting was incorrect. These findings were based on clinical record reviews, facility policy review, direct observations, and staff and resident interviews. The facility's policy requires licensed nurses to initiate and monitor oxygen therapy per physician orders, but in these cases, the prescribed flow rates were not maintained, resulting in deviations from the required oxygen administration for all three residents.
Failure to Properly Label and Discard Multi-Dose Insulin Pens
Penalty
Summary
Surveyors observed that the facility failed to comply with its own policy and accepted professional standards regarding the labeling and storage of multi-dose medications. During an inspection of a medication cart on the Lilac Hall unit, one multi-dose insulin pen of Insulin Degludec and one multi-dose pen of Insulin Glargine were found to be opened and in use without being labeled with the date they were first accessed. Additionally, a multi-dose insulin pen of Insulin Aspart was found with a date indicating it had been opened on July 1, 2025, but was still available for use past its manufacturer-recommended discard date of July 28, 2025. Interviews with an LPN and the DON confirmed that these insulin pens were opened, available for resident use, and not properly dated or discarded according to facility policy and manufacturer guidelines. The facility's policy requires that all multi-use medication vials or bottles be labeled with the date they are opened to ensure proper tracking for expiration, which was not followed in these instances.
Failure to Remove Accused Staff and Report Abuse Allegations
Penalty
Summary
Facility administration failed to use its resources effectively and efficiently to ensure resident safety and maintain the highest practicable physical and mental functioning of residents. Specifically, after an allegation of physical abuse by a nurse aide against a resident, the facility did not immediately remove the accused employee from resident contact while the allegation was unresolved. This allowed the employee continued access to residents, placing them at risk. The failure to implement immediate protective measures resulted in Immediate Jeopardy cited at F600. Further review revealed that the facility did not fulfill mandatory reporting obligations for additional abuse allegations involving two other residents and two nurse aides. The facility failed to report these allegations to the State Survey Agency and other required officials, and did not conduct investigations into these incidents. The lack of timely reporting and investigation prevented the facility from determining whether abuse had occurred, identifying and removing potential perpetrators, and implementing protective measures to prevent further harm.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Address and Document Significant Unplanned Weight Loss
Penalty
Summary
A resident with Parkinson's Disease experienced a significant unplanned weight loss, dropping from 133.5 lbs to 111 lbs over a 37-day period, representing a 16.9% decrease. Meal intake records showed variable consumption, and although a dietary note confirmed the weight loss and recommended providing nutritious dessert cups twice daily, there was no documentation that these were offered or consumed. The clinical record also lacked evidence that the resident's physician and representative were notified of the significant weight loss, as required by professional standards and regulatory guidance. Further review revealed that after the significant weight loss was identified, the facility did not obtain weekly weights or conduct a nutritional assessment between the time of the weight loss and a later date. Interviews with facility staff, including the Registered Dietician and the DON, confirmed that the weight loss was not addressed in a timely manner, and the facility could not provide a written policy for monitoring and managing residents' nutritional status. No documentation was available to show that any interventions were implemented to address the resident's weight loss.
Failure to Consistently Document Controlled Substance Counts at Shift Change
Penalty
Summary
Nursing staff failed to consistently follow established procedures for verifying and documenting the count of controlled substances at shift change on two medication carts. Facility policy requires that both the oncoming and outgoing nurses count controlled medications together at the end of each shift, document the count, and report any discrepancies to the director of nursing services. However, a review of narcotic count records revealed multiple instances where the oncoming nurse did not sign off to confirm the count was completed and correct on both the green and lilac nursing unit medication carts. Specifically, on several dates, the required signatures were missing from the narcotic count sheets for both day and night shifts. Staff interviews confirmed that it is the expectation for nursing staff to review and sign off on narcotic count sheets at each shift change. The nursing home administrator acknowledged that the facility did not consistently implement procedures to ensure accurate controlled drug records, as required by facility policy and state regulations.
Failure to Provide Advance Written Notice of Rate Increase
Penalty
Summary
The facility failed to provide advance written notice of a private pay rate increase to a resident who was cognitively intact and responsible for his own financial matters. The resident, who had a history of frequent falls and pneumonia, was admitted with his daughter listed as the emergency and HIPAA contact. According to the facility's admission agreement, a minimum of 60 days' written notice is required before any financial rate increase is implemented. However, billing records showed that the resident's monthly charge increased from $1,200 to $1,567.18 without documented evidence of advance written notification to the resident or his representative. The deficiency was further substantiated when the resident's daughter contacted the Business Office Manager to inquire about the increased charges, and it was confirmed during a staff interview that no written notification had been provided prior to the rate increase. This failure was identified through a review of billing records, clinical documentation, facility policies, and staff interviews, and it was cited as a violation of resident rights under 28 Pa Code 201.29(c)(1).
Failure to Implement Smoking Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its established smoking policy to ensure resident safety and regulatory compliance. Observations revealed that the smoking policy was not posted in a conspicuous and legible manner in the designated smoking area or elsewhere in the facility, as required by the facility's own policy. Additionally, the designated smoking patio lacked necessary fire safety equipment, such as a fire extinguisher or fire blanket, and there was no signage indicating it was a designated smoking area. The only available fire extinguisher was kept inside a locked cabinet within the facility, not accessible in the smoking area where residents regularly smoked. Further review showed that the facility did not conduct required assessments for safe smoking practices for all residents who smoke. Specifically, one cognitively intact resident with a diagnosis of Wernicke's encephalopathy and nicotine dependence was not assessed for safe smoking, despite documented incidents where the resident attempted to light a cigarette using a lighter taken from a staff member and became agitated and verbally aggressive when denied access to the smoking patio. Documentation indicated that the resident was told he could not participate in smoking until assessed by nursing, but this assessment was not completed. Interviews with the DON and NHA confirmed that the facility did not follow its own smoking policy regarding resident assessment, posting of the policy, and provision of fire safety equipment in the designated smoking area. These failures were observed during the survey and corroborated by staff interviews and clinical record reviews.
Failure to Honor Resident's Discharge Preferences and Goals
Penalty
Summary
The facility failed to ensure that the discharge process for a resident with diagnoses including Wernicke's Encephalopathy, alcohol-induced psychotic disorder, alcoholic cirrhosis, and nicotine dependence honored the resident's preferences and goals. The resident, who was cognitively intact, expressed a clear desire to be transferred to a local skilled nursing facility that permitted smoking. Documentation showed that the social worker communicated this preference to the resident's guardian, who authorized the release of records to two local facilities. However, the resident was ultimately transferred to a facility several hours away, contrary to his stated wishes. There was no documentation provided to justify why a local placement was not pursued or why the facility could no longer meet the resident's needs. The social worker was unable to explain the decision to transfer the resident to a distant facility and there was no evidence that the resident was meaningfully involved in the discharge decision-making process. Additionally, the facility could not produce documentation confirming the resident's guardianship status during the survey.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for three residents, resulting in multiple incidents of harm. One resident with severe cognitive impairment, a history of falls, and physical limitations experienced several falls, including one where the resident was left unsupervised while agitated and attempting to climb out of bed. During this incident, the resident fell and struck her head on a nightstand that had been improperly returned to the head of the bed, resulting in a laceration and a subdural hematoma. The same resident later fell from a Broda chair during transport by an untrained staff member who did not adjust the chair to the safe position, resulting in additional lacerations and a hematoma. Another resident with dementia and Parkinson's disease, also severely cognitively impaired, experienced repeated falls and injuries, including abrasions, skin tears, and a laceration requiring staples. The care plan for this resident did not specify the level of assistance required for bed mobility or toileting, and staff were not provided with clear guidance. Despite multiple incidents, the care plan was not updated to address the resident's behavioral triggers or need for increased assistance, and interventions were not individualized or revised to prevent recurrence. A third resident, who was cognitively intact but at risk for wandering, was able to exit the facility unsupervised when the front lobby was left unattended. The resident was found outside the building in the parking lot by a passerby and was returned to the facility without injury. The lapse in supervision occurred because the designated staff member assigned to monitor the lobby was away from the desk, leaving the area unmonitored and allowing the resident to leave the building.
Failure to Provide Timely Written Notice of Room Rate Increase
Penalty
Summary
The facility failed to provide advance written notice of a daily room rate increase to a resident and/or his representative prior to the effective date of the increase. The resident, who was admitted with diagnoses including diabetes and was cognitively intact, was his own responsible party, with his sister listed as an emergency and HIPAA contact. Billing records showed that the daily room rate increased from $350.00 to $550.00, but there was no documented evidence that the resident or his representative received written notification of this change before it took effect. The deficiency was confirmed through review of billing statements, facility documentation, and staff interviews. The resident's sister contacted the Nursing Home Administrator (NHA) via email, stating that neither she nor her brother had seen the notification letter regarding the rate increase until it was provided to her on a later date. The NHA confirmed during an interview that the notice of the rate increase was not sent in a timely manner to the resident or his representative.
Unsanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness for all 78 residents. During a kitchen tour, several unsanitary conditions were observed, including a sticky floor with food, dirt, and debris, and juice machine guns with a buildup of juice. The counter had dried sticky juice, and multiple fruit flies were noted near the juice machine. Opened juice was not dated, and the dry storage room was improperly propped open. On the prep counter, there were uncovered and undated food items, including biscuits, shredded cheese, and light cream that felt warm to the touch. Dried food particles were found on the steam table and plate warmer, and the plate warmer covers were broken. Additional issues included an ice machine not draining properly, resulting in a puddle of water underneath. Expired and undated food items were found, such as cereal, breadcrumbs, marinated vegetables, cut potatoes, tuna fish, mushrooms, lemons, rice, hotdogs, apple sauce, cake, and peanut butter and jelly sandwiches. The janitor's closet was cluttered with boxes, preventing proper storage of cleaning equipment, and dirty garbage cans with sticky lids were noted. These observations were confirmed by the Nursing Home Administrator, indicating a failure to store, prepare, and serve food under sanitary conditions.
Failure to Apply Therapeutic Devices for Resident with Contractures
Penalty
Summary
The facility failed to ensure that therapeutic devices were applied to a resident to maintain proper positioning and support. Resident 48, who was admitted with contractures in both ankles and elbows, was prescribed restorative nursing care that included the use of ankle plantar flexion contracture boots and elbow splints. These devices were to be applied in the morning and removed at night. However, documentation revealed that the contracture boots were not applied or removed as prescribed 29 times in August and 31 times in September. Similarly, the elbow splints were not applied or removed as prescribed 31 times in August and 30 times in September. Observations conducted on October 1, 2, and 3, 2024, confirmed that the resident's contracture boots and elbow splints were not in place. An interview with a nursing assistant on October 2, 2024, revealed that the boots were found in the resident's closet, but the elbow splints were missing. The nursing assistant was unfamiliar with the resident as she did not usually work in that area. The Director of Nursing and the Nursing Home Administrator confirmed the facility's failure to apply the therapeutic devices as required.
Deficiencies in Bowel, Bladder, and Catheter Care
Penalty
Summary
The facility failed to thoroughly assess and evaluate bowel and bladder function and implement individualized approaches for four residents. Resident 20, who was initially continent of bowel, became frequently incontinent, but the facility did not assess this change or develop a specific toileting plan. Resident 48, always incontinent of bowel and bladder, had not been assessed since February 2024, and the facility did not document maintenance care frequency or initiate a two-hour check and change program. Resident 3, always incontinent, had a care plan that failed to identify urinary incontinence and lacked documentation of care plan implementation. Resident 22, with acute cystitis and urine retention, reported that their catheter bag was not emptied regularly, sometimes containing up to 1500 ml of urine. This was confirmed by staff observations. The facility's failure to maintain routine catheter care was acknowledged by the Nursing Home Administrator. These deficiencies indicate a lack of proper assessment and care planning for residents' bowel and bladder needs, as well as inadequate catheter care for Resident 22.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly drug regimen reviews for two residents, as required by their policies and procedures. Resident 42, who was admitted with a diagnosis of dementia, did not have evidence of monthly drug regimen reviews from December 2023 to March 2024. Similarly, Resident 54, diagnosed with Pick's Disease and Alzheimer's disease, also lacked evidence of monthly reviews during the same period. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation for the required monthly medication regimen reviews for both residents.
Failure to Follow Planned Menus for Pureed Diets
Penalty
Summary
The facility failed to adhere to the planned menus for residents requiring a pureed diet on October 1, 2024. The planned menu for the lunch meal included a pureed barbecue cheeseburger, pureed mixed vegetable salad, mashed potatoes, and a pureed sugar cookie. However, during the lunch meal service, it was observed that there were no pickles, pureed marinated mixed vegetables, or pureed sugar cookies available on the tray line as indicated on the menu. Additionally, the meals for four residents were missing the pureed hamburger bun, mixed vegetables, and sugar cookie. An interview with the District Kitchen Manager confirmed that all planned items should have been prepped on the tray line prior to the meal service, indicating a failure to follow the planned menus. This deficiency was identified under 28 Pa. Code 211.6 (a)(f) Dietary Services.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve foods at safe and palatable temperatures for one out of five residents, as observed during a survey. According to the federal regulation 483.60(i)-(2), food temperatures should not be in the danger zone, which is above 41 degrees Fahrenheit and below 135 degrees Fahrenheit, to prevent the rapid growth of pathogenic microorganisms. The scheduled lunch time for dining room cart one was 12:20 PM and for dining room cart two was 12:25 PM. However, dining room cart one left the kitchen at 12:35 PM and dining room cart two at 12:48 PM. By approximately 1:15 PM, staff were observed pushing a cart of meal trays out of the dining room to the nursing unit, indicating that the trays had been sitting for about 40 minutes before being delivered to residents who did not go to the dining room. A test tray conducted with the District Kitchen Manager revealed that the food temperatures were not within the safe range. The cheeseburger was at 90 degrees Fahrenheit, the French fries at 82 degrees Fahrenheit, and the coleslaw at 65 degrees Fahrenheit, all of which were below the minimum safe temperature of 135 degrees Fahrenheit. The coffee was at 125 degrees Fahrenheit. The cheeseburger bun appeared soggy, the fries were soggy and limp, and the coleslaw appeared watery. The District Kitchen Manager confirmed that the facility failed to ensure palatable temperatures for the residents' meals, which is a violation of 28 Pa. Code 211.6(a)(f) Dietary services.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated residents' preferences for four out of nine residents reviewed. During an observation of the lunch meal tray line, it was noted that Resident 8 and Resident 60 did not receive the pasta salad they requested, as it was not available. Similarly, Resident 58 did not receive the fruit cocktail they requested, and Resident 49 was served a plain cheeseburger instead of the requested barbecue cheeseburger. An interview with the Nursing Home Administrator confirmed that the dietary staff did not accommodate these residents' meal preferences, which is a violation of dietary services and resident rights regulations.
Failure to Secure Resident Medical Records
Penalty
Summary
The facility failed to ensure the security and organization of resident medical records, as observed on multiple occasions. On October 1, 2024, at both 10:00 AM and 2:00 PM, a copier room in the front lobby was found unlocked and open, containing multiple resident medical records that were not secured, allowing potential access by non-medical staff. Similar observations were made on October 2, 2024, at 11:00 AM, with the copier room again found unlocked and open with unsecured resident medical records. Additionally, on October 3, 2024, at approximately 9:15 AM, an unlocked shed outside the facility was observed to contain a box of papers with resident medical records on the floor, also unsecured and accessible to non-medical staff. An interview with the Nursing Home Administrator on October 4, 2024, confirmed the facility's failure to maintain systematically organized, readily accessible, and secured resident medical records.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents requiring such measures. The facility's policy, reviewed in March 2024, mandates that personal protective equipment (PPE) should be stored near residents' rooms and accessible to staff, with EBP employed during high-contact resident care activities. However, during an environmental tour on October 1, 2024, it was observed that there was no evidence of EBP for any of the five residents who required them, despite their medical conditions necessitating such precautions. The residents involved included those with conditions such as tube feeding, foley catheters, and open wounds, which require EBP to prevent the spread of infections. The Director of Nursing confirmed that no EBP were implemented for these residents at the time of the survey. This lack of implementation was in violation of the facility's own policies and the guidance issued by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) regarding the use of EBP in nursing homes.
Unsanitary Storage Conditions for Resident Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition within its storage area. During a tour of the storage area, two sheds were found to contain resident equipment in unsanitary conditions. Dirt and debris were present on the floor, and mattresses were placed directly on the shed floor, accumulating dirt and dust. Pails for bedside commodes were also on the floor, with one containing a dried white and brown substance. Bed bolsters were uncovered and lying on the floor, and boxes of air mattresses were placed directly on the dirty floor. Additionally, wheelchairs were observed with dirty wheels and dust. An interview with the Nursing Home Administrator confirmed the facility's failure to ensure the safe operating condition of essential equipment, as the administrator could not provide an explanation for the poor storage conditions of the residents' items.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by their policy. During an observation of the food and nutrition services department, small flies resembling fruit flies were seen around the juice machine. The facility's pest control contract, initiated in June 2024, covered treatment for roaches, ants, mice, rats, and common spiders, but did not include services for flies. Despite monthly treatments by the pest control company, invoices from June to September 2024 did not indicate any identification or treatment for flies in the kitchen. The Nursing Home Administrator confirmed the lack of evidence for an effective pest control program, noting that the facility had recently signed a contract with a new pest management company and could not provide information on pest management prior to June 2024.
Failure to Respond Timely to Resident Requests
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life and ensures they are treated with dignity. This deficiency was identified through resident and staff interviews, where it was reported that staff did not respond timely to residents' requests for assistance. During a group interview with alert and oriented residents, five residents expressed concerns about long wait times for staff assistance, often exceeding 30 minutes. This delay resulted in residents soiling themselves and having to remain in soiled briefs while waiting for staff. Despite raising these concerns multiple times during resident council meetings, no resolution was documented in the meeting minutes or grievances over the past three months. The Nursing Home Administrator and Director of Nursing acknowledged that residents should be treated with dignity and respect but could not explain the untimely staff responses.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unclean and unsafe environment for residents. On October 1, 2024, observations in the main dining room revealed debris, food particles, and sticky floors, with dirty place settings and a resident breakfast tray left from the morning meal service. Additionally, a resident's bathroom in a specific room had a hole in the wall covered with plaster, and the floor was dirty with debris near the hole. Further observations on October 3, 2024, showed similar issues in the main dining room, with debris and dried sticky spills on the floor. An interview with the Nursing Home Administrator confirmed the facility's failure to maintain a clean and sanitary environment for residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for three residents, leading to deficiencies in addressing individual needs and preferences. Resident 56, who was admitted with a diagnosis of depression, exhibited increased behaviors when his wife, also a resident, would push him back to his room early in the evening, asking staff to put him to bed. Resident 56's personal preference for bedtimes and the resulting frustration and agitation were not addressed in his care plan, as noted during the survey ending on October 5, 2024. Additionally, the care plans for Residents 58 and 60, both identified as smokers, did not address their smoking habits. Resident 58, admitted with a diagnosis of Bipolar disorder and muscle weakness, had a care plan last updated on May 24, 2024, which failed to include smoking. Similarly, Resident 60, admitted with Chronic Obstructive Pulmonary Disease and End Stage Renal Disease, also had no mention of smoking in their care plan. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to ensure comprehensive care plans were developed.
Failure to Update Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 47, who was part of a sample of 18 residents. The facility's policy on discharge planning, last reviewed in July 2024, mandates that each resident's discharge needs be evaluated and the plan updated based on any changes in the resident's condition or needs. Resident 47, who was admitted with a diagnosis of bipolar disorder, had an intact cognitive status as indicated by a BIMS score of 15 from an assessment conducted in July 2024. Despite this, the resident's comprehensive care plan, which identified them as a long-term placement since December 2023, was not revised or updated by the time of the survey in September 2024. Additionally, there was no documented evidence in the social service notes from September 2023 to October 2024 that the resident's discharge plans and desires were discussed. The Nursing Home Administrator confirmed the facility's failure to revise and implement a discharge plan based on the resident's desires.
Failure to Conduct RN Assessment After Resident Fall
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that a registered nurse (RN) conducted a thorough assessment of a resident following an unwitnessed fall. The incident involved a resident who was admitted with diagnoses including diabetes and muscle weakness. On the morning of September 3, 2024, the resident was found lying on his back on the floor by his bed. An LPN, identified as Employee 5, was called to the scene by the resident's roommate and conducted an initial assessment, noting no apparent injuries and initiating neuro checks and 15-minute checks. However, upon further review of the resident's clinical record, it was found that there was no documented evidence of an RN assessment following the fall, which is a requirement according to professional standards of practice. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that an RN had not completed the necessary assessment. The failure to document and maintain accurate records as required by the Pennsylvania Code was noted as a deficiency in the facility's nursing services.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to provide effective fall interventions for a resident who experienced repeated falls. The resident, who was admitted with diagnoses including schizophrenia, anxiety, and hypertension, had a documented history of falls on multiple occasions. Despite being identified as high risk for falls, the facility did not implement new interventions after a fall on July 29, 2024, until September 21, 2024, during which time the resident experienced seven additional falls. The care plan for the resident included interventions such as keeping the bed in the lowest position, using bilateral floor mats, a bed alarm, and ensuring the call bell was within reach, but these were not effectively implemented. An observation on October 3, 2024, revealed that the resident was attempting to get out of a wheelchair with the chair alarm sounding, and the call bell was not within reach. Interviews with facility staff, including a registered nurse and the Nursing Home Administrator, confirmed that the resident's call bell was not accessible and that the facility was responsible for implementing the care plan to mitigate fall risks. The deficiency was noted under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(c)(d)(5), which pertain to resident care policies and nursing services.
Failure to Maintain Clean Nebulizer Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a manner that promotes optimal functioning for a resident diagnosed with Parkinson's disease. The resident had a physician's order for nebulizer treatment with Ipratropium-Albuterol solution to be administered as needed for shortness of breath or coughing. Observations revealed that the nebulizer machine on the resident's nightstand had a dried brown substance and black spots on it. The tubing and mask were stored in a visibly dirty bag, which was not dated to indicate when the tubing was put into use. The mask inside the bag also had dried spots, indicating a lack of proper cleaning and maintenance. Despite multiple observations over three consecutive days, the nebulizer equipment remained in the same unclean condition. The Director of Nursing confirmed the facility's failure to maintain the resident's nebulizer equipment. This deficiency was identified under the 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services, highlighting the facility's non-compliance with its own policy for nebulizer therapy, which requires cleaning and proper maintenance of the equipment after each use.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to consistently attempt non-pharmacological interventions before administering narcotic pain medication to a resident with neuropathy and hypertension. The resident had a physician's order for oxycodone to be given as needed for moderate to severe pain. A review of the resident's Medication Administration Records (MAR) for July, September, and October 2024 revealed multiple instances where the pain medication was administered without prior attempts at non-pharmacological interventions. Specifically, in September 2024, out of 29 doses of oxycodone administered, 24 were given without trying non-pharmacological methods first. In October 2024, six out of eight doses were administered similarly, and in July 2024, two out of four doses were given without such attempts. An interview with the Nursing Home Administrator and Director of Nursing confirmed the lack of evidence for consistent attempts at non-pharmacological interventions before administering the as-needed pain medication.
Failure to Account for Controlled Drug Disposition
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure accurate accounting of controlled drugs, specifically for one resident. The facility's policy, titled Discharge Medications, requires nursing staff to forward completed drug disposition records to medical records and provide a complete list of the resident's medications upon discharge. However, upon review of the clinical record for a resident who was discharged home, it was found that there was no record of the disposition of the resident's remaining supply of Alprazolam 0.5 mg, an antianxiety medication. This oversight was identified during a review of the resident's closed record, indicating a failure to comply with the facility's policy. During an interview with the Nursing Home Administrator (NHA), it was revealed that there was no additional information available regarding the medication disposition, and the NHA expected that the medication disposition should have been completed according to the facility's policy. This deficiency was noted under the regulation 28 Pa. Code 211.12(d)(1)(3)(5) concerning nursing services.
Inadequate Monitoring and Intervention for Psychoactive Drug Use
Penalty
Summary
The facility failed to adequately monitor behaviors and potential adverse consequences of psychoactive drug use for a resident, identified as Resident 24. The resident was admitted with diagnoses including neuropathy and hypertension. A physician's order dated September 9, 2024, prescribed Ativan 1mg as needed for anxiety, but did not include a stop date for the medication. On multiple occasions, specifically on September 15, September 29, September 30, and October 1, 2024, the resident received doses of Ativan without documentation of the specific behaviors that warranted its administration. Additionally, there were no attempts to use non-pharmacological interventions before administering the medication. An interview with the Director of Nursing on October 4, 2024, confirmed that the nursing staff failed to record adequate monitoring for behaviors and did not consistently attempt non-pharmacological interventions prior to administering the as-needed antianxiety drug. This lack of documentation and intervention attempts led to the deficiency noted in the report.
Failure to Adhere to Multi-Dose Medication Storage Procedures
Penalty
Summary
The facility failed to implement and adhere to procedures for the proper storage and use by dates of multi-dose medications in the medication storage room. During an observation of the medication room, a registered nurse was present when it was discovered that a multi-dose vial of Lidocaine Hydrochloride Injection USP and a vial of Tuberculin Purified Protein Derivative were opened and available for use but were not dated or initialed as required by the facility's policy. The facility's policy, last reviewed on July 8, 2024, mandates that the expiration or beyond use date on the medication label must be checked prior to administering, and when opening a multi-use container, the nurse's initials and the date opened should be recorded on the container. An interview with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to adhere to acceptable storage and use by dates for multi-dose medications. This deficiency is in violation of 28 Pa. Code 211.9(a)(1)(k) Pharmacy services and 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to effectively identify and address ongoing deficient practices related to the unnecessary administration of psychotropic anti-anxiety medications. During a survey ending November 26, 2024, it was found that the facility did not implement non-pharmacological interventions prior to administering as-needed psychotropic anti-anxiety medication to residents, as required by their plan of correction. Specifically, Resident 6 was administered Alprazolam 1.5 mg without documented attempts of non-pharmacological interventions, despite the facility's procedures to ensure such interventions were attempted first. The Director of Nursing confirmed that the nursing staff did not provide evidence of non-pharmacological interventions for Resident 6 before administering 15 doses of Alprazolam between November 16, 2024, and November 25, 2024. This oversight indicates that the facility failed to identify Resident 6 as at risk of noncompliance with the administration of psychotropic medications, leading to a recurrence of similar quality deficiencies in the area of unnecessary psychotropic medication use.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. Specifically, for one resident, there was no documented evidence that the facility had communicated essential information such as advance directives, special instructions, precautions for ongoing care, or comprehensive care plan goals to the hospital to which the resident was transferred. This deficiency was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of communication documentation for the resident's transfer.
Failure to Provide Written Notice of Emergency Transfer
Penalty
Summary
The facility failed to provide a written notice regarding an emergency transfer to the hospital for one resident, identified as Resident 30, out of a sample of 19 residents. The clinical record review showed that Resident 30 was transferred to the hospital on June 5, 2024, and later returned to the facility. However, there was no documented evidence that written notices were provided to the resident or their responsible parties. These notices should have included the reason for the transfer, the effective date, the location to which the resident was transferred, contact information for the Office of the State Long-Term Care Ombudsman, and, if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. An interview with the Nursing Home Administrator confirmed the absence of such notifications.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to a resident or their representative upon transfer to a hospital. This deficiency was identified during a review of clinical records and staff interviews, which revealed that Resident 30 was transferred to the hospital on June 5, 2024, and subsequently returned to the facility. However, there was no documented evidence that the resident or their responsible parties were informed in writing about the facility's bed-hold policy at the time of transfer. An interview with the Director of Nursing confirmed the absence of such documentation.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive and healthcare wishes, resulting in a deficiency. Resident 1, who was admitted with severe cognitive impairment and required maximum assistance, had a Healthcare Directive indicating a DNR and do not hospitalize status. However, this directive was not uploaded to the resident's electronic record until three days after admission. Consequently, when the resident was found unresponsive, the facility staff, unaware of the resident's wishes, sent the resident to the hospital. The deficiency occurred because the agency nurse on duty during the resident's admission failed to note the resident's code status while verifying the admission physician's order. This oversight led to the facility staff being unaware of the resident's advance directive, resulting in the resident being hospitalized contrary to their documented wishes. The baseline care plan, which noted the resident's DNR and do not hospitalize status, was completed only after the hospitalization had occurred.
Failure to Assist Resident in Replacing Lost Hearing Aid
Penalty
Summary
The facility failed to ensure that a resident received necessary services to maintain hearing ability, as evidenced by the loss of one of the resident's hearing aids. The resident, who was admitted with dementia and hypertension, was noted to have severe cognitive impairment and required maximum assistance for daily activities. Upon admission, the resident had bilateral hearing aids, but a nurse's note indicated that only one hearing aid was present at the bedside. Despite a search by social services and a grievance filed by the resident's daughter, the missing hearing aid was not located. The facility's response to the grievance indicated that the resident's old hearing aids were used as a temporary solution, and the resident's daughter planned to file an insurance claim for the lost device. However, there was no evidence that the facility assisted in replacing the missing hearing aid or in coordinating resources, appointments, or transportation for the resident. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that no plans were made to replace the device or assist the resident's daughter in securing its replacement.
Deficient Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain acceptable practices for food storage and service, which increased the risk of food-borne illness. During a tour of the unit resident pantry area, it was observed that the resident refrigerator was damaged, with the vent covered in dirt, debris, and rust. Food splatter and debris were found behind the microwave, and the garbage can was overflowing without a lid, with food splatter on it and the wall behind it. The pantry floor was stained with a reddish-brown substance, indicating poor sanitation practices. During lunch tray line service, unsanitary practices were observed, including unlabeled shakes without thaw or discard dates, as required by the manufacturer's instructions. The cook was seen handling food with gloved hands but failed to change gloves or perform hand hygiene after touching other kitchen surfaces. Additionally, the resident meal trays showed significant wear, with deep scratches and worn non-slip surfaces, inhibiting proper cleaning and sanitizing. The food service manager confirmed that sanitary conditions should be maintained to prevent foodborne illness.
Untimely Staff Response to Resident Requests
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This deficiency was identified through a review of grievances and Resident Council meeting minutes, as well as interviews with residents and staff. Residents reported waiting 35 to 40 minutes for staff to answer call bells, with concerns about insufficient nurse aides on the floor. A grievance filed on behalf of a resident noted that staff were observed on their cell phones instead of responding to a call for assistance. Another grievance highlighted that nurse aides at night were not answering calls, and there were not enough nurses for medication administration and evening showers due to staffing issues. Interviews with residents revealed ongoing issues with long wait times for assistance, particularly during the night shift and meal times. One resident reported waiting two hours for help, resulting in distress due to soiled briefs. Another resident mentioned that the wait times have been problematic for the past two to three months. The Nursing Home Administrator acknowledged that residents should be treated with dignity and respect but could not explain the untimely staff responses affecting residents' quality of life. There was no documented evidence that the facility had reviewed nurse staffing adequacy or assignments to ensure timely care.
Failure to Maintain Resident Dignity and Respectful Environment
Penalty
Summary
The facility failed to conduct meal service in a manner respectful of residents' personal dignity, as observed with two residents who were dependent on staff assistance to eat. During meal times, these residents were left waiting with their meal trays in front of them while other residents at the same table began eating. One resident was observed watching another being fed for 12 minutes before receiving assistance. Additionally, the facility did not maintain a respectful environment, as evidenced by staff using foul language within earshot of residents, which was reported by two residents and observed by a surveyor. The facility also failed to ensure that residents maintained a dignified personal appearance. One resident was observed wearing a shirt with visible dandruff-like flakes and a hole, and both this resident and another were wearing bright yellow fall risk bracelets that should have been removed upon admission. These observations were confirmed by the Director of Nursing and the Nursing Home Administrator, who acknowledged that the residents should not have been subjected to these conditions.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in three nursing halls, as observed during a facility tour. In the resident activity room, crumbs, food, and paper debris were found on the floor. The hallway outside the activity room had clumps of hair that remained there for several hours. The nursing station had a brown substance splattered on the handrail and wall, with a buildup of dirt and debris on the handrail and dried liquid stains on the wall. Resident rooms were also found to be unclean, with used tissues, food debris, and stains on the floors and walls. The resident day room had dead insects on the floor, dirt and debris near the exit, and a visible gap in the door corner. Resident interviews corroborated these observations, with one resident expressing dissatisfaction with the cleaning, stating that dirt remained on the floor after cleaning and that the bathroom floor was stained and discolored. Additional observations included a gash in the wall of one resident room and stains or discoloration on the molding strip and floor of another room. The Nursing Home Administrator confirmed that the facility is expected to be maintained in a clean and orderly manner, indicating a failure to uphold this standard.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to develop and implement an effective quality assurance plan to identify and correct ongoing quality deficiencies related to maintaining a safe, clean, and homelike environment. During a revisit survey, it was observed that the entryways of resident rooms had uneven surfaces due to a height difference between the new hallway flooring and the old floor inside the rooms, which could pose a risk for ambulation and mobility. Additionally, the floor molding was missing at the bottom of the nurse's station, and the walls had black scuff marks. The resident shower room was cluttered with nursing supplies, red plastic bins, a mattress, and other equipment stored in a bathroom stall, indicating a lack of proper organization and cleanliness. Interviews with three cognitively intact residents revealed that the resident unit had been under construction for months, but the construction crew had left the areas unfinished, contributing to an unhomelike environment. Furthermore, an observation in the presence of the facility's Assistant Director of Nursing revealed two hand-held hair dryers hanging from their cords and plugged into an electrical outlet, creating a potential electrical hazard. These observations indicate that the facility's quality assurance monitoring plans were inadequate in identifying and preventing the recurrence of similar deficiencies.
Failure to Promptly Assess Resident's Change in Condition
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not promptly assessing a resident who displayed possible signs and symptoms of a change in condition. Resident 38, who was part of a sample of 15 residents, experienced an unwitnessed fall and was found face down on the floor with a small bump on the forehead. Prior to the fall, a nurse aide reported to the RN Supervisor that the resident appeared confused and had an unusual skin color, but there was no documented evidence that the RN Supervisor assessed the resident's condition in response to this report. The incident report and witness statements indicate that the resident was confused, had a brownish-yellow skin color, and was not acting like himself. Despite these observations, there was no prompt assessment by the RN Supervisor before the fall occurred. The Director of Nursing confirmed the lack of evidence for a timely assessment of the resident's condition, which is a deficiency in nursing services as per the professional standards of practice.
Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to consistently and accurately monitor the weights of two residents, leading to a deficiency in maintaining their nutritional health. According to the facility's Weight Policy and Procedure Facility Guidelines, monthly weights should be documented in the resident's electronic medical record, and weekly weights should be conducted until stabilization is determined by the Dietitian and Interdisciplinary Team. However, the facility did not adhere to these guidelines for Residents 51 and 47, resulting in significant unplanned and undesired weight loss that was not promptly addressed. Resident 51, who had diagnoses including aphasia, diabetes, and muscle weakness, experienced a significant weight loss of 10.4 pounds or 7.8% in just 17 days. Despite the Registered Dietitian's recommendation on February 8, 2024, to monitor the resident's weight weekly, the facility failed to obtain weekly weights. The resident's weight was recorded only on February 19 and then again approximately three weeks later on March 15, indicating a lack of consistent monitoring. This oversight continued despite the resident's ongoing weight fluctuations and the need for close monitoring due to previous COVID-19 infection and diuretic therapy. Similarly, Resident 47, who had diagnoses including protein-calorie malnutrition and a history of breast cancer, experienced an 18.4-pound or 12.6% weight loss in 17 days. The facility did not conduct a reweight to confirm this change, and weekly weights were not obtained as planned for close monitoring. The Registered Dietitian noted the significant weight loss and recommended fortified foods and Ensure Plus supplements, but the facility's failure to conduct weekly weights hindered effective monitoring of the resident's nutritional status. The Director of Nursing confirmed the facility's failure to ensure weekly weights were obtained for both residents following their significant weight loss.
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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