Bethlehem South Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethlehem, Pennsylvania.
- Location
- 2021 Westgate Drive, Bethlehem, Pennsylvania 18017
- CMS Provider Number
- 395429
- Inspections on file
- 26
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Bethlehem South Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not verify the professional license or registration status of three newly hired staff members before they began working, as required by policy. Required checks with the state board of nursing and nurse aide registry were not completed prior to employment, and this was confirmed by the Human Resources Manager.
The facility did not follow its own policy for changing and maintaining respiratory equipment, as evidenced by undated or outdated oxygen humidifiers and tubing for several residents with respiratory conditions. Observations and interviews confirmed that equipment was not changed at the required intervals, and one resident reported her humidifier bottle was not changed often enough, with the bottle found nearly empty.
A resident with intact cognitive ability and multiple medical diagnoses was found with an unsecured potassium pill at her bedside after an LPN placed the medication there without documented assessment for self-administration, contrary to facility policy. The DON confirmed that no assessment had been completed.
A resident with significant mobility and cognitive impairments was found on the floor with injuries after being assisted by only one staff member, contrary to the care plan requiring two staff for bed mobility. The incident, which met criteria for potential neglect, was not reported to state or local authorities as required by facility policy. The DON confirmed the failure to report.
A resident dependent on staff for ADLs, with a history of stroke, aphasia, and a feeding tube, was observed with significant oral secretions and mucus on bed sheets, indicating a lack of required oral hygiene assistance. Despite staff presence, oral care was not provided as per facility policy, and the resident expressed a desire to be cleaned. The DON confirmed that oral care should be completed twice daily and as needed.
A resident with a stage four sacral pressure ulcer and multiple comorbidities did not consistently receive wound care as ordered, with several instances lacking documentation of daily dressing changes over a three-month period. The DON confirmed that there was no evidence of care provided or refusals documented on those dates.
A resident with left-sided paralysis and cognitive impairment, who was dependent on staff for care, did not have a physician-ordered palm guard applied to the affected hand during multiple observations. The DON confirmed the device was to be in place as ordered, indicating a failure to follow the care plan for maintaining or improving range of motion.
The facility did not provide required written discharge or transfer notices to the Office of the State LTC Ombudsman for eight residents who were transferred to the hospital after changes in condition. This was confirmed by clinical record review and by the DON, who acknowledged that the notifications were not sent.
A resident with dementia and limited mobility, who required supervision for bathing, was left unsupervised in the shower for over an hour after being told to ring the call bell when finished. The resident was later found to have fallen, and facility leadership confirmed that adequate supervision was not provided.
A resident with multiple diagnoses, including diabetes and dementia, experienced increased fatigue, poor appetite, loose stools, vomiting, and low blood pressure. Nursing staff did not document an assessment after vomiting and failed to notify the physician or responsible party about these changes. The resident was later transferred to the ER due to an acute change in condition.
The facility did not meet the required nurse aide staffing levels across all shifts for seven consecutive days. Specifically, the facility failed to provide the minimum number of NAs per residents on the day, evening, and night shifts, as per the regulation effective July 1, 2024.
The facility did not meet the required LPN staffing levels during the night shift, failing to provide one LPN per 40 residents on two nights. This deficiency was identified through a review of nursing time schedules.
The facility failed to provide the mandated 3.2 hours of direct resident care per day on six out of seven days reviewed. Nursing time schedules showed that care hours fell short on multiple days, with residents receiving between 2.54 and 3.17 hours of care, indicating a consistent shortfall in meeting regulatory requirements.
The facility failed to maintain adequate grooming and hygiene for two residents, both of whom were observed with long and dirty fingernails despite care plans requiring regular maintenance. One resident had hemiplegia and chronic pain, while the other had dementia and a hand contracture. The administrator confirmed the oversight in nursing services.
The facility failed to apply prescribed devices for two residents to prevent decline in range of motion. One resident with hemiplegia was observed without a required elbow splint, and another with dementia and hand contracture was without a prescribed carrot device. There was no documentation of refusal by the residents, and the administrator confirmed the devices should have been applied.
The facility failed to provide written notification to residents and their representatives before hospital transfers, as required by policy and federal regulations. Three residents, with conditions such as schizoaffective disorder, heart disease, and acute kidney failure, were transferred without documented written notifications. The Administrator confirmed this deficiency, which had been previously cited.
A facility failed to provide timely vision services to a resident with vision problems, despite a referral and a request from the resident's Power of Attorney. The resident was observed without glasses, which were necessary for watching television as per her care plan. The Social Services Director confirmed the lack of eye care services.
Failure to Verify Professional Licensure Prior to Employment
Penalty
Summary
The facility failed to verify the professional license or registration status of three out of five newly hired employees prior to the start of their employment. According to the facility's Abuse Prohibition policy, screening of potential hires should include checking with the appropriate licensing boards and registries to ensure there is no history of abuse, neglect, or mistreatment of patients. Personnel file reviews showed that for three employees, there was no evidence that inquiries were submitted to the state board of nursing or the state nurse aide registry before or after they began working. The Human Resources Manager confirmed that these required checks were not performed prior to employment.
Failure to Maintain and Change Respiratory Equipment per Policy
Penalty
Summary
The facility failed to provide adequate respiratory care and maintain respiratory equipment in a sanitary manner for four of six sampled residents who utilized respiratory equipment. Facility policy required oxygen humidifiers to be changed every seven days and as needed, and nebulizer equipment to be changed daily. However, observations revealed that humidification bottles on oxygen concentrators for multiple residents were not dated, and nebulizer tubing and oxygen tubing were not changed according to policy. For example, one resident's nebulizer tubing was dated nine days prior to observation, and another resident's oxygen tubing was dated eleven days prior. In one case, a resident's oxygen tubing was not dated at all. Additionally, a resident reported that her oxygen humidifier bottle was very low and had not been changed since a specific date, which was confirmed by observation of an almost empty humidifier bottle and a dated bag indicating it had not been changed in over two weeks. Interviews with the Director of Nursing confirmed that the facility's policy was not followed, as equipment was not changed at the required intervals. These deficiencies were identified through review of clinical records, resident and staff interviews, and direct observation.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's capability to self-administer medications as required by its own policy. The policy states that residents must be evaluated for self-administration, require a physician's order, and, when applicable, be provided with a secure, locked area for medications. A resident with diagnoses including pneumonia, heart failure, and hypokalemia, and with intact cognitive ability per the Minimum Data Set assessment, was observed sleeping with a potassium pill in a medication cup on her bedside table. An LPN confirmed that the medication had been placed in front of the resident 45 minutes to an hour prior to observation. There was no documentation of an assessment for self-administration, and the medication was not secured in the resident's room. The Director of Nursing confirmed that the required assessment had not been completed.
Failure to Report Alleged Neglect Following Resident Fall
Penalty
Summary
The facility failed to report an alleged violation of potential neglect involving a resident with chronic obstructive pulmonary disease, intellectual disabilities, and lumbago sciatica. The resident, who had some memory impairment and required assistance of two staff for transfers and was totally dependent for bed mobility, was found lying on the floor beside the bed with a bruise on the right shin and bleeding from the right second toenail. Facility documentation indicated that only one nurse aide was present during the incident, despite the care plan requiring two staff for bed mobility. The aide reported that the resident slid from the bed to the floor while being turned. There was no documented evidence that the facility reported this incident of alleged neglect to the appropriate state and local agencies as required by facility policy. The Director of Nursing confirmed in an interview that the incident was not reported to the authorities, which is a violation of both facility policy and state regulations.
Failure to Provide Required Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with aphasia, right-sided weakness due to stroke, difficulty swallowing, and a feeding tube, who was dependent on staff for activities of daily living, did not receive appropriate oral hygiene assistance as required by facility policy. The policy specified that oral care should be performed at least twice daily. Clinical record review and care plan documentation indicated the resident required staff assistance for oral care. During observations, the resident was found with thick yellow secretions on the lips and inside the mouth, as well as pools of green mucus on the bed sheets, and staff present at the bedside did not provide oral care. The resident expressed a desire to be cleaned, and the DON confirmed that oral care was to be provided twice daily and as needed.
Failure to Provide Ordered Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a stage four sacral pressure ulcer. Clinical record review showed that the resident, who had multiple sclerosis, venous insufficiency, and was dependent on staff for ADLs, had a physician's order for daily wound care, including dressing changes and cleaning. However, treatment administration records revealed multiple instances over three months where there was no documentation that the wound care was completed as ordered. The resident reported that wound care was not always provided as prescribed, and the Director of Nursing confirmed the lack of documentation for both the provision of care and any resident refusals on those dates.
Failure to Implement Ordered Palm Guard for Resident with Limited ROM
Penalty
Summary
A resident with a history of left-sided weakness and paralysis due to a stroke, as well as cognitive impairment and dependence on staff for daily activities, was identified as having a loss of range of motion in the left upper extremity. The care plan included a physician's order for staff to apply a palm guard to the resident's left hand in the morning and remove it in the evening. However, during multiple observations over two days, the resident was found without the palm guard on the affected hand. The DON confirmed that the palm guard was to be in place as ordered by the physician. This failure to implement the ordered intervention resulted in the facility not providing appropriate care to maintain or improve the resident's range of motion.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for eight out of nine residents who were transferred out of the facility. Clinical record reviews showed that multiple residents were transferred to the hospital following changes in their conditions, but there was no documented evidence that the required notifications were sent to the Ombudsman. This deficiency was identified for residents who experienced transfers on various dates, with some residents being transferred more than once without the appropriate notifications being documented. During an interview, the Director of Nursing confirmed that the written discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman as required. The lack of documentation and notification was consistent across all identified cases, indicating a systemic failure to comply with the notification requirements outlined in 28 Pa. Code 201.14(a).
Failure to Provide Adequate Supervision During Showering
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with diagnoses including dementia, chronic obstructive pulmonary disease, and emphysema. Clinical records and the Minimum Data Set (MDS) assessment indicated that the resident required supervision or touch-assistance for showering or bathing, and the care plan specified a need for setup assistance due to limited mobility. On the morning of July 5, 2025, a nurse aide set the resident up in the shower and instructed the resident to ring the call bell when finished. The aide checked on the resident after ten minutes, but then left the resident unsupervised for over an hour. When the aide returned, the resident was found to have fallen in the shower room. Facility leadership confirmed that adequate supervision was not provided during this time.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a physician and responsible party following a significant change in a resident's condition. Clinical records show that a resident with diabetes mellitus, dementia, and mood disorder experienced increased tiredness, poor meal intake, and multiple episodes of loose stools. Later, the resident vomited during supper and was found to have low blood pressure. Despite these changes, there was no documented nursing assessment after the vomiting episode, nor was there any documentation that the physician or responsible party was notified of the resident's condition changes. The resident was subsequently transferred to the emergency room the following morning due to an acute change in condition.
Failure to Meet Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) as per the regulation effective July 1, 2024. During the review of nursing time schedules from March 2 to March 8, 2025, it was found that the facility did not provide the minimum number of NAs per residents across all shifts. Specifically, on the day shift, the facility did not meet the requirement of one NA per ten residents on March 2, 4, 7, and 8. On the evening shift, the facility failed to provide one NA per eleven residents on all days from March 2 to March 8. Additionally, on the night shift, the facility did not meet the requirement of one NA per fifteen residents on March 2, 4, 5, 6, 7, and 8. This deficiency was observed for all seven days reviewed, indicating a consistent failure to comply with the staffing regulation.
Plan Of Correction
1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratio is met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse aide staffing ratio and PPD requirements. 4) Weekly audit of nurse aid ratios will be conducted for 60 days by NHA/designee to assure nurse aid ratio is met. Tracking and trends to be submitted to QAPI committee for any further action needed.
Inadequate LPN Staffing During Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one Licensed Practical Nurse (LPN) for every 40 residents during the night shift. This deficiency was identified during a review of nursing time schedules for the period from March 2 to March 8, 2025. Specifically, on the nights of March 3 and March 4, 2025, the facility did not have the required number of LPNs on duty, resulting in inadequate staffing levels for the residents during the overnight hours.
Plan Of Correction
1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratio is met. 3) Nursing admin and scheduler will be re-educated on new July 1 LPN nurse staffing ratio and PPD requirements. 4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratio is met. Tracking and trends to be submitted to QAPI committee for any further action needed.
Deficiency in Meeting Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per day. A review of nursing time schedules from March 2 to March 8, 2025, revealed that on six out of the seven days reviewed, the facility did not provide the required hours of care. Specifically, on March 2, 2025, residents received 2.54 hours of care; on March 3, 2025, 3.06 hours; on March 4, 2025, 3.15 hours; on March 6, 2025, 2.87 hours; on March 7, 2025, 3.17 hours; and on March 8, 2025, 2.94 hours. This deficiency indicates a consistent shortfall in meeting the mandated care hours for residents during the specified period.
Plan Of Correction
5640 1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.2 hours of direct care is met. Master PCA has been updated and the facility is hiring to schedule needs to ensure ratios and HPPD at being met. 3) Nursing admin and scheduler will be re-educated on July 1 nurse staffing and PPD requirements. 4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to QAPI committee for any further action needed.
Failure to Maintain Resident Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents, as observed during a survey. Resident 39, who has diagnoses including hemiplegia, hemiparesis following cerebral infarction, adult failure to thrive, and chronic pain in the left hand, was found with long and dirty fingernails on two consecutive days. The care plan for Resident 39 indicated that staff were responsible for checking and maintaining the resident's fingernail hygiene on bath days and as needed, but this was not adhered to. Similarly, Resident 67, diagnosed with unspecified dementia and contracture of the left hand, was also observed with long and dirty fingernails on two separate occasions. The care plan for Resident 67 required staff to ensure fingernail hygiene, but this was not executed. The facility administrator confirmed that the residents' fingernails should have been trimmed and cleaned regularly, indicating a lapse in the provision of necessary nursing services as per the care plans.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline and/or improve range of motion for two residents. Resident 39, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed without a prescribed left elbow extension splint on two separate occasions. The care plan required the splint to be applied during morning care and removed at night, but there was no documentation indicating that the resident refused to wear the splint. Similarly, Resident 67, diagnosed with unspecified dementia and a contracture of the left hand, was observed without a prescribed carrot device on two occasions. The care plan specified that the carrot should be applied at all times except during range of motion exercises and morning and evening care. Again, there was no documentation to suggest that the resident refused the device. The facility's administrator confirmed that the devices should have been applied according to the care plans.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as required by their policy and federal regulations. This deficiency was identified for three out of four sampled residents who were transferred to the hospital due to changes in their medical conditions. The facility's policy, last reviewed on March 14, 2024, mandates that residents and their representatives be notified in writing prior to any transfer or discharge. However, there was no documented evidence that such notifications were provided for the transfers of these residents. Resident 1, diagnosed with schizoaffective disorder and epilepsy, was transferred to the hospital on June 29, 2024, following a change in condition. Resident 2, with a diagnosis of heart disease, was transferred on May 31, 2024, and Resident 3, suffering from acute kidney failure, was transferred on July 7, 2024. In an interview conducted on July 26, 2024, the Administrator confirmed the absence of documented written notifications for these transfers, which is a violation of CFR 483.15 (C)(3)-(6)(8) Notice Requirements Before Transfer/Discharge. This issue had been previously cited on November 2, 2023.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely treatment and services to maintain visual abilities for a resident with vision problems. The resident, who had diagnoses including anxiety and hypertension, was observed without her glasses while watching television, despite her care plan indicating she should use corrective lenses daily for this activity. A referral for eye care services was made in March, and the resident's Power of Attorney also requested these services in April. However, there was no documented evidence that the resident received the necessary eye care services. The Social Services Director confirmed that the resident had not been seen for eye care services as required.
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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