Bedford Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bedford, Pennsylvania.
- Location
- 136 Donahoe Manor Road, Bedford, Pennsylvania 15522
- CMS Provider Number
- 395221
- Inspections on file
- 30
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Bedford Post Acute during CMS and state inspections, most recent first.
A resident with parkinsonism, who was cognitively intact, and their family raised concerns about staff providing drinking water from a shared bathroom sink. Although the concern was reported to staff and management, it was not documented in grievance logs or investigated according to facility policy. The DON did not consider the issue a grievance, and staff did not receive clear instructions on where to obtain water for the resident.
A resident with cognitive impairment and a history of falls was not provided with the prescribed fall prevention intervention of non-skid socks, as documented in the care plan. Despite the care plan update after a previous fall, the resident was found on the floor following another fall, and staff confirmed the intervention was not in place at the time.
Three residents with significant medical needs, including cognitive impairment, pressure ulcers, Parkinson's, stroke, and contractures, were provided with air mattresses without documented safety assessments. Clinical record reviews, observations, and DON interviews confirmed that no safety evaluations were completed prior to the use of air mattresses for these residents.
A resident with cognitive impairment and multiple medical conditions had several doses of oxycodone-acetaminophen signed out on the controlled drug record, but there was no documentation on the MAR to confirm administration. The DON confirmed the lack of required documentation for these controlled medication doses.
A resident with cognitive impairment and dementia received PRN Ativan for anxiety on several occasions without documented attempts at non-pharmacological interventions beforehand, contrary to facility policy and regulatory requirements. The DON confirmed that these interventions should have been tried prior to medication administration.
A medication error rate above 5% was identified when a nurse crushed an extended-release opioid tablet and failed to instruct a resident to rinse and spit after using a Dulera inhaler, both actions contrary to manufacturer guidelines. The errors were confirmed by the nurse and DON, and involved a resident with cognitive impairment and multiple medical conditions.
A registered nurse left a medication cart unlocked and unattended in a hallway while administering medications to a resident, contrary to facility policy requiring carts to be locked when out of sight. Both the nurse and the DON confirmed the cart should have been secured.
A nurse left a laptop displaying a resident's MAR open and unattended on a medication cart in the hallway, making confidential medical information visible to unauthorized individuals. Both the nurse and the DON confirmed this action did not comply with facility policy regarding resident privacy.
The facility did not ensure that the licenses of two nurses were verified with the State Board of Nursing and failed to complete a Nurse Aide Registry check for one nurse aide before employment, as confirmed by personnel file reviews and staff interviews. Required verifications were not documented prior to staff start dates, contrary to facility policy.
A resident who was cognitively intact and at risk for constipation did not receive all required interventions according to the facility's bowel protocol and physician orders. Despite no bowel movement for six days, only Milk of Magnesia was administered, with no documentation that a Dulcolax suppository or saline enema was given as required. The DON confirmed the protocol was not followed.
A resident with cognitive impairment and a back fracture did not receive a physician-recommended TLSO brace after hospital discharge. The facility was unable to obtain the brace from suppliers, and although therapy staff could have purchased it, they were told not to proceed. The resident's family intended to obtain the brace through a specialist but did not follow through, resulting in the resident never receiving the brace and experiencing a prolonged delay in physical therapy.
A resident with a nephrostomy tube and renal insufficiency experienced a change in condition, including dark red drainage and pain. Nursing staff notified supervisors and placed a call to the tele-health physician, but did not follow facility policy to escalate contact when there was no timely response. The physician returned the call over an hour later, after the resident's family had already arranged hospital transfer.
The facility was found to have unsanitary food service conditions due to a thick accumulation of dust on a vent above shelves where clean dishes and utensils were stored. This was observed during kitchen inspections and confirmed by the Director of Dining Services.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated issues with MDS assessments, care plan development and timing, medication storage and labeling, and food service operations. Despite developing plans of correction involving audits, the committee was ineffective in ensuring compliance with regulations.
A facility failed to follow infection control guidelines for a resident with a feeding tube and tracheostomy. Staff did not wear gowns during high-contact care activities, despite Enhanced Barrier Precautions being in place. Interviews confirmed the need for both gloves and gowns, highlighting a lapse in adherence to infection control policies.
The facility failed to provide three nurse aides with the required 12 hours of annual in-service training. A review of records and staff interviews confirmed the absence of documentation for the necessary training hours.
The facility failed to follow physician orders for two residents. One resident with dementia was not properly monitored after a fall, as neurological checks and oxygen saturation levels were not documented. Another resident with endocarditis was not weighed daily as ordered, which was necessary to determine the need for diuretic medication. The DON confirmed these deficiencies.
The facility failed to maintain the dignity of three residents with indwelling urinary catheters by not covering their urinary drainage bags, as required by facility policy. Observations revealed that a resident in a wheelchair and another in bed had uncovered bags, visible to others. Interviews with nursing staff and the administrator confirmed the lack of privacy covers, violating the policy.
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization. Two residents were transferred to the hospital without documented evidence of written notice to their responsible parties. The Director of Nursing confirmed the lack of compliance with notification requirements.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS did not reflect the administration of an antiplatelet medication, despite physician orders and MAR records confirming its use. Another resident's discharge status was incorrectly coded as a hospital transfer, while nursing notes confirmed a discharge home. These errors were confirmed by the DON.
The facility failed to develop comprehensive care plans with specific interventions for several residents, including those with MDRO, tracheostomies, feeding tubes, and PICC lines. Despite being on Enhanced Barrier Precautions, these residents lacked individualized care plans, as confirmed by the DON.
A facility failed to update a resident's care plan to reflect the use of a foley catheter instead of urinary incontinence. Despite a physician's order for a foley catheter, the care plan inaccurately indicated urinary incontinence. Observations confirmed the resident had a urinary drainage bag, and the DON acknowledged the care plan was not revised.
A facility failed to complete a discharge summary for a resident, including a recapitulation of the resident's stay. Although discharge instructions and medications were provided to the resident and their son, there was no documented evidence of a completed discharge summary three months after the discharge, as confirmed by the Medical Records Coordinator.
A facility failed to obtain a physician's order for a urinary catheter for a resident admitted with urinary retention. The resident had a foley catheter in place upon arrival, but there was no documented physician's order from admission until a week later. The care plan noted the need for the catheter, and the DON confirmed the oversight.
The facility did not complete annual performance evaluations for two nurse aides by their due dates. Evaluations for these aides were overdue, and there was no documented evidence of completion. This was confirmed by the Nursing Home Administrator.
A facility failed to label a multi-dose container of Latanoprost Ophthalmic Solution with the date it was opened, as observed in one medication cart. The manufacturer's instructions require the bottle to be stored at room temperature for six weeks once opened, but there was no evidence of when it was opened. An LPN and the DON confirmed the oversight, which violated the facility's medication storage policy.
The facility failed to obtain necessary hospice documentation for two residents receiving hospice care. One resident with end-stage bladder cancer lacked the Hospice Certification of Terminal Illness in their record, while another resident with dementia did not have the Hospice Benefit of Election form documented until it was faxed by the hospice provider. Interviews confirmed the absence of these documents, indicating non-compliance with facility policy.
The facility did not follow its grievance policies, failing to log and investigate grievances for two residents. A resident's concern about staff availability at night was not documented or investigated, and another resident's complaint about call bell response times and pain medication was not thoroughly investigated or documented.
A facility failed to update a resident's care plan to reflect their current mobility status. Despite a nursing note indicating the resident was ambulating independently, the care plan still required a mechanical lift for transfers. Observations confirmed the resident's independent mobility, and the DON acknowledged the care plan should have been updated.
Failure to Investigate Resident Grievance Regarding Drinking Water Source
Penalty
Summary
The facility failed to thoroughly investigate and address a grievance raised by a resident and their family regarding the source of drinking water provided to the resident. The resident, who was cognitively intact and diagnosed with parkinsonism, expressed being upset when a staff member obtained drinking water from a shared bathroom sink. The resident reported this concern to staff and informed their power of attorney. Despite these reports, a review of the resident's clinical record and the facility's grievance logs showed no documentation of the complaint or any related family concerns. Interviews with nurse aides confirmed awareness of the family's preference against using bathroom water and indicated that the concern had been reported to nursing staff and management. However, staff reported that they had not received clear guidance on where to obtain water for the resident. The DON acknowledged that the concern was reported by the resident's spouse but did not consider it a grievance, citing the family's history of multiple complaints and deeming this issue a non-issue. As a result, the facility did not initiate a formal grievance investigation or resolution process as required by policy.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and injury prevention interventions for one resident as required by its own fall management policy. The policy stated that the interdisciplinary team would review falls, discuss and care plan recommended interventions, and update the care plan and Kardex accordingly. A resident with Alzheimer's dementia, cognitive impairment, and a recent history of falls was found on two separate occasions sitting or lying on the floor after apparent falls. After the first fall, the care plan was updated to include the use of non-skid socks at bedtime as a preventive measure. Despite this intervention, the resident experienced a second fall in her room during the early morning hours. Documentation and staff interviews confirmed that the resident was not wearing non-skid socks at the time of the second fall, as required by the updated care plan. The Director of Nursing verified that the intervention was not in place when the incident occurred. This failure to ensure that the prescribed fall prevention measure was implemented resulted in a deficiency under the cited nursing services regulation.
Failure to Complete Air Mattress Safety Assessments
Penalty
Summary
The facility failed to complete safety assessments for three residents who were provided with air mattresses. For each of these residents, clinical record reviews and observations confirmed that there was no documented evidence that an assessment for potential safety hazards related to the use of an air mattress was conducted prior to its placement on the resident's bed. This was further confirmed through interviews with the Director of Nursing, who acknowledged that safety assessments had not been completed for these residents before the air mattresses were put in use. The residents involved had significant medical conditions and care needs. One resident was cognitively impaired, required assistance with daily care, had a Stage 3 pressure ulcer, and diagnoses including dementia and Parkinson's Disease. Another resident was cognitively impaired, required extensive assistance, and had diagnoses of Parkinson's, stroke, and sarcopenia. The third resident was cognitively intact but required extensive assistance and had a history of hip fracture and contractures. Despite these vulnerabilities, the facility did not assess the safety of air mattress use for these individuals as required.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to facility policy, documentation of narcotic administration must be completed in accordance with applicable law, including recording necessary information on appropriate forms. For a resident with cognitive impairment and multiple diagnoses, including Parkinson's disease, stroke, and sarcopenia, physician orders required administration of oxycodone-acetaminophen as needed for pain. The controlled drug record indicated that doses of this medication were signed out on several occasions. However, review of the Medication Administration Record (MAR) revealed no documented evidence that the medication was actually administered to the resident on the dates and times listed in the controlled drug record. The Director of Nursing confirmed that there was no documentation of medication administration on the MAR for those dates and times, despite facility policy requiring such documentation.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary psychotropic medications by not attempting non-pharmacological interventions prior to administering as-needed antianxiety medication. Facility policy required that person-centered, non-pharmacological approaches be used to minimize or discontinue psychotropic medication use unless contraindicated. However, for one resident with cognitive impairment, dementia, and a history of restlessness/agitation, there was no documented evidence that such interventions were attempted before administering Ativan (Lorazepam) on multiple occasions. Review of the resident’s clinical records and Medication Administration Record (MAR) showed that Ativan was given several times over a two-month period without documentation of prior non-pharmacological interventions. This was confirmed in an interview with the Director of Nursing, who acknowledged that these interventions should have been attempted before administering the medication. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication administration errors observed during 29 opportunities, resulting in a 6.90 percent error rate. Facility policy and manufacturer guidelines specify that certain medications, such as Oxycontin extended-release tablets, must not be crushed, and that oral inhalers like Dulera require the resident to rinse and spit out water after use. During medication administration, a registered nurse crushed an extended-release Oxycontin tablet before giving it to a resident, contrary to both the medication label and manufacturer instructions. The resident involved was cognitively impaired, dependent on staff for care, experiencing pain, and had multiple diagnoses including hip and humerus fractures, asthma, and respiratory failure. The same nurse also administered Dulera inhaler to the resident and provided a drink of water afterward, rather than instructing the resident to rinse and spit as required by the manufacturer. Both the nurse and the Director of Nursing confirmed these errors during interviews.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency occurred when a registered nurse left a medication cart unlocked, unattended, and out of sight in the hallway while administering medications to a resident in their room. Facility policy, dated February 14, 2025, requires that medication carts remain locked when out of sight or unattended. During the observation, the nurse confirmed that the cart was not locked as required. The Director of Nursing also confirmed that the cart should have been locked when unattended. This incident was identified during a review of facility policies, direct observation, and staff interviews.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency was identified when a registered nurse left a laptop open on top of a medication cart in the hallway, displaying the Medication Administration Record (MAR) for one resident. This occurred during medication administration, when the nurse walked away from the cart to administer medications in a resident's room, leaving the confidential medical information visible to staff, residents, and visitors passing by. The facility's policy requires employees to protect resident privacy and block unnecessary access to medical records, but this was not followed in this instance. Both the nurse and the Director of Nursing confirmed that the laptop screen should not have been left open and visible in the hallway.
Failure to Verify Nursing Licenses and Nurse Aide Registry Status Prior to Employment
Penalty
Summary
The facility failed to ensure that nursing licenses and nurse aide registry statuses were properly verified prior to employment for multiple staff members. Specifically, there was no documented evidence that the licenses of a registered nurse and a licensed practical nurse were checked with the State Board of Nursing before their respective start dates. Additionally, a nurse aide began employment without documented verification of her standing on the Pennsylvania Nurse Aide Registry until several days after her start date. The facility's policy required background checks and verification of licensure or registry status to prevent abuse, neglect, exploitation, and misappropriation. However, review of personnel files and staff interviews confirmed that these verifications were not completed as required, with reliance placed on a contracted company for background and licensure checks. The Human Resources/Payroll Director acknowledged that the necessary verifications were not documented prior to the staff members' start dates.
Failure to Follow Bowel Protocol and Physician Orders for Constipated Resident
Penalty
Summary
The facility failed to follow physician's orders and its own bowel protocol for a resident identified as being at risk for complications due to constipation. According to the facility's policy, if a resident does not have a bowel movement after three days, Milk of Magnesia (MOM) should be administered, followed by a Dulcolax suppository on day four if MOM is ineffective, and a saline enema on day five if both previous interventions fail. For the resident in question, the bowel record showed no bowel movement for six consecutive days. While MOM was administered on the third day without effect, there was no documented evidence that the Dulcolax suppository was given on the fourth day or that a saline enema was administered on the fifth day, as required by both physician's orders and facility protocol. The resident was cognitively intact, frequently incontinent of bowel and urine, and required assistance with transfers and hygiene. She reported recent constipation during an interview. The DON confirmed that the bowel protocol was not followed for this resident during the specified period. Clinical record reviews and staff interviews corroborated that the required interventions were not provided or documented as ordered.
Failure to Provide Physician-Recommended TLSO Brace
Penalty
Summary
A resident with cognitive impairment and a history of a back fracture was assessed as requiring a TLSO brace following a hospital discharge. The hospital discharge records specified the need for the brace, and this recommendation was documented in the resident's clinical records. Despite this, the facility was unable to obtain the brace from one medical supplier, and another supplier could not provide it in a timely manner. The physical therapy department was tasked with obtaining the brace, but was ultimately told not to purchase it. The resident's daughter expressed a desire for the resident to be seen by a brain and spine specialist to obtain the brace, but this did not occur. As a result, the resident never received the prescribed TLSO brace. The Director of Therapy confirmed that she could have purchased the correct brace but was instructed not to do so. The absence of the brace led to a delay in physical therapy for several months, as the resident did not have the necessary support for therapy to proceed.
Failure to Follow Physician Notification Protocol for Change in Condition
Penalty
Summary
The facility failed to follow its established protocols for notifying a physician of a resident's change in condition. According to facility policy, if a tele-health physician does not respond within five minutes, staff are required to re-initiate the consult or contact the medical director for assistance. On the date in question, a resident with a nephrostomy tube and a history of renal insufficiency was observed to have dark red drainage from the tube, along with complaints of nausea and left flank pain. The resident's vital signs were recorded, and both the RN supervisor and charge nurse were notified. A call was placed to the tele-health physician, but no further attempts to contact a physician were documented after the initial call. The tele-health physician did not return the call until over an hour later, during which time the resident's family requested hospital transfer and called 911. Interviews with the DON and Nursing Home Administrator confirmed that staff did not follow the required steps outlined in the facility's policy when the physician did not respond promptly. This failure to adhere to protocol resulted in a delay in physician notification regarding the resident's change in condition.
Unsanitary Food Service Conditions
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as evidenced by observations and staff interviews. During a review of the facility's work history report, it was noted that the vent in the kitchen was last documented as inspected on July 25, 2024. However, during observations on July 30 and July 31, 2024, a thick accumulation of dust was found on a large vent in the ceiling above two metal shelves where clean dishes and utensils were stored. This unsanitary condition was confirmed by the Director of Dining Services during an interview on July 31, 2024.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, improper development and timing of care plans, and issues with medication storage and labeling. Additionally, there were problems with food procurement, storage, preparation, and serving. These deficiencies were noted in surveys conducted on August 17, 2023, and March 27, 2024, and were found to persist in the survey ending August 1, 2024. The facility had previously developed plans of correction that involved conducting audits and reporting the results to the QAPI committee. However, the committee was ineffective in implementing these plans to ensure compliance with regulations. The repeated deficiencies indicate that the QAPI committee did not successfully address the issues related to assessment accuracy, care plan development and timing, medication management, and food service operations.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) for one of the residents reviewed, identified as Resident 21. The resident was cognitively impaired, required extensive assistance for daily care, and had a feeding tube and a tracheostomy. According to the facility's policy on Enhanced Barrier Precautions (EBP), staff were required to wear both gloves and gowns during high-contact care activities for residents with indwelling medical devices, regardless of their MDRO status. However, during medication administration and respiratory care, staff members did not comply with these guidelines. On two separate occasions, staff members failed to wear the required gown while providing care to Resident 21. During a medication administration, an LPN only wore gloves while accessing the resident's feeding tube, despite the signage indicating EBP measures were in place. Similarly, a respiratory therapist provided respiratory and tracheostomy care wearing only gloves. Interviews with the Infection Control Preventionist confirmed that both staff members should have worn gowns in addition to gloves while performing these tasks, as per the facility's infection control policy.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that three out of five nurse aides reviewed received the required 12 hours of in-service training annually. Specifically, Nurse Aide 1, Nurse Aide 2, and Nurse Aide 3 did not have documented evidence of completing the necessary training hours within their respective annual periods. This deficiency was confirmed through a review of the facility's list of nurse aides, their hire dates, and training hours, as well as staff interviews. An interview with the Infection Control Preventionist/Staff Educator further confirmed the lack of documentation for the required training hours for these nurse aides.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. For Resident 44, who had dementia and required assistance for care needs, a fall occurred when the resident attempted to transfer from a wheelchair to a bed without help, resulting in a head injury. The physician ordered neurological checks and monitoring of oxygen saturation levels, but the facility did not complete the neurological evaluation and failed to document oxygen saturation levels as required. For Resident 68, who was cognitively intact and receiving intravenous medication for endocarditis, the physician ordered daily weight monitoring to determine the need for furosemide administration in case of significant weight gain. However, the facility did not weigh the resident on several specified days, as documented in the Medication Administration Record. The Director of Nursing confirmed these lapses in following physician orders for both residents.
Failure to Maintain Dignity of Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of three residents who had indwelling urinary catheters by not covering their urinary drainage bags, as required by the facility's policy. The policy, dated March 1, 2024, mandates that staff refrain from practices that are demeaning to patients, such as keeping urinary catheter bags uncovered. Observations on July 29, 2024, revealed that Resident 48, who required assistance with personal hygiene and had a diagnosis of renal insufficiency, was seen with an uncovered urinary drainage bag while in his wheelchair in both his room and the therapy room. Similarly, Resident 65, who had urinary retention and required an indwelling foley catheter, was observed in the therapy room with an uncovered urinary drainage bag attached to her wheelchair. Additionally, Resident 67, who had a neurogenic bladder and required assistance for personal care, was observed lying in bed with an uncovered urinary drainage bag visible from the door. Interviews with nursing staff confirmed that the urinary drainage bags for these residents were not covered, which was against the facility's policy. The Nursing Home Administrator also confirmed that all urinary drainage bags should have privacy covers, as per the facility's policy. This failure to adhere to the policy resulted in a deficiency related to maintaining the dignity of the residents.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their legal guardians regarding the reasons for hospitalization, as required by regulations. This deficiency was identified for two residents during a review of clinical records and staff interviews. Resident 19, who had diagnoses including Parkinson's disease, dementia, and COPD, was transferred to the emergency department after a choking incident. Despite the transfer, there was no documented evidence that a written notice was provided to the resident's responsible party explaining the reason for the transfer. Similarly, Resident 22, who had schizophrenia and was independent with personal care needs, was transferred to the hospital following hallucinations and increased aggressive behaviors. Again, there was no documented evidence of a written notice being provided to the resident's responsible party regarding the reason for the transfer. An interview with the Director of Nursing confirmed that the facility did not provide the required written notices for these hospital transfers.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical records. For one resident, there was an error in coding Section N0415I1 of the MDS, which pertains to antiplatelet medications. Despite physician's orders indicating that the resident was to receive 75 mg of Plavix daily for clot prevention, and the Medication Administration Record confirming administration during the seven-day look-back period, the MDS was not coded to reflect this. The Director of Nursing confirmed the oversight, acknowledging that the resident had indeed received the medication during the specified period. Another deficiency was identified in the discharge documentation for a second resident. The discharge MDS inaccurately coded the resident's discharge status as a transfer to a short-term general acute hospital, while nursing notes indicated that the resident was discharged home in stable condition. This discrepancy was confirmed by the Director of Nursing, who verified that the resident was discharged home and not to a hospital. These inaccuracies in the MDS assessments highlight the facility's failure to maintain accurate clinical records as required by regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for five residents, as required by their policy on person-centered care plans. The policy mandates that each resident's care plan should describe the services to be provided, any specialized services, and any services not provided due to treatment refusal. However, the facility did not adhere to this policy for several residents, leading to deficiencies in care planning. Resident 18, who had a diagnosis of Multi Drug Resistant Organism (MDRO), was observed to be on Enhanced Barrier Precautions, but there was no documented evidence of a comprehensive care plan addressing this. Similarly, Resident 21, who was in a persistent vegetative state and had a tracheostomy and feeding tube, was also on Enhanced Barrier Precautions without a corresponding care plan. Resident 23, who required continuous oxygen therapy, lacked a care plan detailing specific interventions for this need. Additionally, Resident 66, who had a PICC line and required dialysis, and Resident 68, who had a PICC line and was receiving intravenous medication, both required Enhanced Barrier Precautions. However, there was no documented evidence of comprehensive care plans for these residents. Interviews with the Director of Nursing confirmed the absence of these care plans, highlighting a systemic issue in the facility's care planning process.
Failure to Update Resident Care Plan for Foley Catheter
Penalty
Summary
The facility failed to update and revise a resident's care plan to accurately reflect the resident's specific care needs. Resident 48, who was admitted with chronic kidney disease and required assistance with personal care, had a physician's order for a foley catheter for urinary drainage dated July 13, 2024. However, the care plan dated July 9, 2024, inaccurately indicated that the resident was incontinent of urine, and an active care plan dated July 14, 2024, noted the presence of an indwelling foley catheter. Observations on July 29, 2024, confirmed the resident had a urinary drainage bag attached to his wheelchair. An interview with the Director of Nursing on August 1, 2024, revealed that the care plan was not revised to reflect the change from urinary incontinence to the use of a foley catheter, leading to the deficiency.
Failure to Complete Discharge Summary for a Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a discharged resident. A nursing note indicated that the resident was discharged from the facility, and verbal and written discharge instructions and medications were provided to the resident and the resident's son. However, as of three months later, there was no documented evidence of a completed discharge summary for the resident. This was confirmed through an interview with the Medical Records Coordinator.
Failure to Obtain Physician's Order for Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary catheter for a resident who was admitted with urinary retention. The resident, who was admitted on July 22, 2024, had a foley catheter in place upon arrival at the facility. Despite the care plan indicating the need for the catheter due to urinary retention, there was no documented evidence of a physician's order for the catheter from the date of admission until July 29, 2024. Observations confirmed the presence of the catheter, and the Director of Nursing acknowledged the absence of the required physician's order during an interview.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, the performance evaluations for two nurse aides, identified as Nurse Aide 2 and Nurse Aide 5, were not conducted by their respective due dates. Nurse Aide 2's evaluation was due on January 20, 2024, and Nurse Aide 5's evaluation was due on May 13, 2024. As of July 31, 2024, there was no documented evidence that these evaluations had been completed. This deficiency was confirmed during an interview with the Nursing Home Administrator on July 31, 2024.
Failure to Label Multi-Dose Eye Drops
Penalty
Summary
The facility failed to label multi-dose containers of eye drops with the date they were opened, as observed in one of the two medication carts reviewed. Specifically, a bottle of Latanoprost Ophthalmic Solution 0.005 percent, used for reducing elevated fluid pressure in the eye, was found on Cart 2 without a date indicating when it was opened. This oversight was identified during an observation on August 1, 2024, at 3:26 p.m. The manufacturer's instructions for this medication, dated November 3, 2023, specify that once opened, the bottle may be stored at room temperature for six weeks. However, there was no evidence on the bottle to determine when it was opened or when it should be discarded. The deficiency was confirmed through interviews with the staff. A Licensed Practical Nurse responsible for Cart 2 acknowledged that the bottle was opened but not dated, which was against the facility's policy. The Director of Nursing also confirmed that the bottle should have been dated upon opening. The facility's policy, dated March 15, 2024, mandates that medications be stored properly, following the manufacturer's or provider pharmacy recommendations to maintain their integrity and ensure safe, effective drug administration. This failure to adhere to labeling protocols was a violation of the facility's medication storage policy and the nursing services regulation 28 Pa. Code 211.12(d)(1).
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents who received hospice services. The facility's policy, dated March 15, 2024, required the interdisciplinary team member to obtain the most recent hospice plan of care, hospice election form, and the physician's certification and recertification of terminal illness. However, for Resident 29, who had end-stage bladder cancer and was rarely understood, there was no documented evidence of the Hospice Certification of Terminal Illness in the clinical record as of July 31, 2024. Similarly, Resident 34, who had dementia and was understood, did not have the Hospice Benefit of Election form documented in their clinical record until it was faxed by the hospice provider. The resident started hospice care on May 30, 2024, but the required documentation was not present in the record until a later date. Interviews with the Nursing Home Administrator confirmed the absence of these critical documents in the residents' clinical records, indicating a failure to comply with the facility's policy and regulatory requirements.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policies by not maintaining a log of all grievances received and not ensuring timely responses to grievances for two residents. Resident 4, who was alert and oriented, expressed a concern during a Resident Council Meeting about the lack of staff to assist residents into bed at night. Despite addressing this concern with the Director of Nursing, there was no documented evidence that the grievance was logged or investigated as per the facility's policy. The Director of Nursing acknowledged that an official grievance form was not completed and no further investigation was conducted at that time. Additionally, Resident 7 filed a grievance regarding long call bell response times and not receiving pain medications. The facility failed to document a thorough investigation of this grievance, including interviews with staff on duty during the incident and verification of the resident's medication administration. There was no summary of findings or conclusions regarding the resident's concerns, nor any documented corrective actions taken by the facility. The Nursing Home Administrator confirmed the lack of documentation and investigation into Resident 7's grievance.
Failure to Update Resident Care Plan for Mobility Status
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect their current care needs, as required by their policy. The policy mandates that care plans be customized to each resident's preferences and needs, and reviewed and revised by the interdisciplinary team after each assessment. In this case, the care plan for a resident with a history of seizures and traumatic brain injury was not updated to reflect their improved mobility status. The resident's care plan, dated March 4, 2024, indicated that they had an activities of daily living self-care deficit and required a mechanical lift for transfers, despite a nursing note from December 8, 2023, indicating that the resident was ambulating independently. Observations on March 27, 2024, confirmed that the resident was transferring and ambulating independently throughout the facility. However, there was no documented evidence that the care plan had been updated to remove the requirement for a mechanical lift. An interview with the Director of Nursing on the same day confirmed that the care plan should have been updated to reflect the resident's current ability to transfer independently without the use of a mechanical lift.
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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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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