Bethlen Hm Of The Hungarian Rf Of America
Inspection history, citations, penalties and survey trends for this long-term care facility in Ligonier, Pennsylvania.
- Location
- 66 Carey School Road, Ligonier, Pennsylvania 15658
- CMS Provider Number
- 395552
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Bethlen Hm Of The Hungarian Rf Of America during CMS and state inspections, most recent first.
Staff failed to maintain and report issues with the call bell system on one nursing unit. An LPN admitted to unplugging the call bell monitor at the nurse’s station because it was too loud during report and then plugging it back in afterward. Other staff, including another LPN and a maintenance worker, were aware that the call system had been unplugged on multiple occasions but did not report this to a supervisor as required by facility policy. Another LPN later discovered the call bell monitor unplugged and out of place, then reconnected it and notified the ADON. These actions and inactions resulted in the call bell system being disabled on the unit for periods of time, contrary to professional standards and facility policy.
The facility failed to report an allegation of staff-to-resident abuse to state authorities as required by its abuse policy and regulations. A resident with hemiplegia, aphasia, and dementia, who could usually understand and be understood, allegedly indicated to a family member that a nurse was rough while repositioning him and told him to "shut up," describing the staff member by shift and physical characteristics. An LPN later acknowledged the resident had reported someone being rough, and leadership became aware of the allegation and conducted staff interviews, but the resident was not interviewed before discharge and the allegation was never reported to the Department of Health.
Two residents with cognitive impairment and behavioral symptoms were given Ativan on multiple occasions without documented attempts at non-pharmacological interventions, despite physician orders and facility policy requiring such measures prior to medication administration.
The facility did not provide required written notifications of hospital transfers, bed-hold notices to responsible parties, or notifications to the ombudsman for three residents with significant medical needs who were transferred to the hospital. These deficiencies were confirmed through record review and staff interviews.
Surveyors identified that MDS assessments for four residents were inaccurately coded, failing to reflect administration of antibiotics, antianxiety, antidepressant, and anticonvulsant medications as documented in the MAR and physician orders. These discrepancies were confirmed through record review and staff interviews.
A resident with an indwelling urinary catheter was observed with an uncovered urinary drainage bag visible from the doorway, contrary to facility policy requiring privacy covers. Staff and the administrator confirmed the lack of a privacy cover, resulting in a failure to maintain the resident's dignity.
A resident with COPD and diabetes was found to have a room with significant gouges in the drywall behind the bed, resulting from previous headboards with bolts. The damage was visible during multiple observations, and both the maintenance and nursing directors confirmed the wall should have been free of such damage, but it was not.
A resident was administered Acetaminophen in excess of the physician-ordered maximum daily dosage on two occasions. The MAR showed that the resident received 3,650 mg of Acetaminophen in a 24-hour period, exceeding the prescribed 3,000 mg limit. The DON confirmed the over-administration of the medication.
A resident with mobility issues and a physician's order for wheelchair leg rests was transported by a RN without the required leg rests in place. Both the RN and the Nursing Home Administrator confirmed that the leg rests should have been used during transport.
A resident with an indwelling urinary catheter did not receive required catheter care or monitoring of urinary output as outlined in facility policy, care plan, and physician orders. Review of records showed no documentation of these tasks over two months, and the Nursing Home Administrator confirmed the care and documentation were not completed.
Two residents did not receive proper respiratory care: one had an oxygen concentrator and related equipment that were not cleaned or changed as ordered, and another received continuous oxygen therapy without a physician's order. These deficiencies were confirmed by facility leadership and observed during the survey.
A resident who was cognitively intact and receiving an antianxiety medication had a pharmacy consultant's recommendation for a Gradual Dose Reduction (GDR) of Zoloft that was not addressed by the physician for several months, despite facility policy requiring timely response to such recommendations.
Surveyors identified that expired blood collection sets and tubes were still available for use, and an open vial of Tubersol was not labeled with the date it was first accessed. An LPN and the Nursing Home Administrator confirmed these expired supplies were in circulation and that the opened vial was not properly dated, in violation of facility policy and federal regulations.
Dietary staff did not consistently wear beard coverings while handling food, and open food containers in a unit refrigerator were found without required labeling of resident names and dates. Both the dietary director and an LPN confirmed that these practices did not meet facility policy or professional standards.
A resident who was cognitively impaired and required substantial assistance was receiving PEG tube and pleasure feeds, but nurse aide documentation was incomplete or missing for multiple shifts. Staff interviews confirmed that the resident received the feeds, but the required documentation was not consistently entered into the clinical record.
The QAPI committee failed to correct recurring deficiencies related to maintaining a safe, clean, homelike environment, accurate MDS assessments, proper labeling and storage of drugs and biologicals, and food procurement. Despite previous plans of correction and audits, the same issues were identified in subsequent surveys, showing that the committee did not effectively implement or sustain corrective actions.
A resident with a Stage 1 pressure ulcer and requiring maximum staff assistance did not consistently receive barrier cream as ordered to prevent further skin breakdown, as evidenced by missing documentation over multiple shifts. The resident later developed a Stage 2 pressure wound, and the DON confirmed the lack of documented care.
Nursing staff did not obtain required physician's orders before inserting an indwelling urinary catheter and performing straight catheterizations to collect urine samples for a resident who was cognitively intact and required assistance with daily care. The DON confirmed that these procedures were conducted without the necessary orders, contrary to facility policy.
Surveyors observed that food items in two resident kitchenettes were not properly dated, labeled, or secured, with several opened and undated or unlabeled items such as chicken broth, milk, salads, and ice cream found in refrigerators and freezers. The DON confirmed these items should have been secured, dated, and labeled per facility policy.
A resident, who was moderately cognitively impaired and required supervision, fell while attempting to sit in front of a piano. Despite facility policy requiring a registered nurse (RN) assessment after such incidents, no RN assessment was documented. An LPN who witnessed the fall confirmed the lack of RN involvement, and the Director of Nursing cited staffing shortages as a contributing factor.
A resident with Alzheimer's disease and severe cognitive impairment experienced a fall, but the LTC facility failed to document the incident and subsequent assessment in the clinical records as required by policy. An LPN and the DON confirmed the lack of documentation, which was necessary following the fall investigation.
The facility failed to meet the required NA-to-resident staffing ratios, with insufficient NAs provided during both day and overnight shifts on several days in December 2024. The deficiency was confirmed through a review of nursing schedules and an interview with the Nursing Home Administrator, who acknowledged the shortfall.
The facility did not meet the required LPN-to-resident staffing ratios on two occasions during the evening shift. With a census of 72 residents, only 2.14 LPNs were available instead of the required 2.40. Similarly, with 65 residents, only 2.13 LPNs were present instead of 2.17. No additional higher-level staff were available to compensate for these deficiencies.
The facility failed to maintain a clean and homelike environment by allowing uncovered buckets of old food scraps to be placed in hallways and lounge areas. Staff were directed to scrape leftover food into these buckets, which were then wheeled through the facility. This practice was confirmed by the Assistant Director of Nursing and Infection Preventionist as not homelike.
The facility failed to notify residents, their representatives, and the ombudsman in writing about hospital transfers for five residents, as required by policy. These residents were transferred for various medical reasons, including pulmonary issues, unresponsiveness, head injury, and urinary retention. The Director of Nursing confirmed the absence of documentation for these notifications, violating resident rights and facility policy.
The facility failed to update care plans for several residents, including one with a fluid restriction, another with a history of elopement, and others with medication changes. The care plans did not reflect these changes, as confirmed by the DON and other staff.
A facility failed to obtain necessary physician's orders for a resident's tube feeding care, including NPO status, verification of tube placement, and administration methods. The resident, with quadriplegia, sometimes received feedings via a pump without documented orders, as confirmed by staff interviews.
A facility failed to ensure a resident and/or their representative had the opportunity to develop an advance directive. The resident, who was cognitively impaired and dependent on care due to conditions like hemiplegia and aphasia, had no documented evidence of being informed about their rights to advance directives. This was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation in the resident's medical records.
A facility did not complete a significant change MDS assessment for a resident who was placed on hospice services due to heart failure. The RAI User's Manual requires this assessment within 14 days of a significant change, but there was no documentation of its completion. This was confirmed by the DON and Director of Case Management.
The facility failed to accurately complete MDS assessments for two residents, leading to incorrect documentation of wanderguard alarm use and wandering behavior. One resident's alarm use was not recorded despite physician orders and TAR confirmation, while another resident's wandering incident was not reflected in the MDS assessment.
The facility failed to create comprehensive care plans for three residents, including one with a prosthetic leg, another with incontinence issues, and a third on anticoagulant and antiplatelet medications. The absence of these care plans was confirmed by the Assistant Director of Nursing.
The facility failed to clarify physician's orders for three residents, leading to improper medication administration and lack of documentation for therapeutic devices. Two residents with feeding tubes had oral medication orders that were not adjusted for tube administration. Another resident with quadriplegia had missing orders for PRAFO boots and a wrist splint, which were not documented or clarified upon admission.
A facility failed to perform a required physical assessment after a resident with severe cognitive impairment and dementia eloped. The resident was found outside after door alarms were triggered, but no assessment was documented or reported to the physician, as confirmed by the DON.
A facility failed to follow physician's orders for a resident with congestive heart failure, chronic respiratory failure, and COPD. The orders included a daily fluid restriction and regular weight monitoring, but records showed no documentation of adherence to these orders. The DON confirmed the lack of documentation for both fluid restriction and weight monitoring.
A facility failed to implement non-pharmacological interventions before administering Ativan to a resident with Alzheimer's, dementia, and depression. Despite policy requirements, the facility did not document any non-pharmacological attempts prior to administering the medication for sobbing and anxiety, as confirmed by the Assistant DON.
The facility failed to secure emergency narcotic medications as per policy, storing them in an unsecured refrigerator. This was confirmed by a nurse and the Assistant DON, acknowledging the medications were not properly secured.
The facility failed to maintain proper temperatures for beverages, as observed on the 300 hall. Beverages, including milk and juice, were stored on a cart without cold containers, resulting in them being warm to the touch. Interviews confirmed that these drinks were intended to be refrigerated for the next meal. The Director of Nutritional Services acknowledged that the drinks were available to residents at inappropriate temperatures.
The facility did not comply with food safety standards by failing to label and date food items in the walk-in refrigerator and freezer. Observations revealed several unlabeled and undated food items, contrary to the facility's policy. The Dietary Manager confirmed the oversight.
The facility's QAPI committee failed to address recurring deficiencies effectively, as identified in a recent survey. Despite having developed plans of correction following a previous survey, the facility did not successfully implement these plans to maintain compliance with regulations. Deficiencies were related to MDS assessments, care plans, professional standards, quality of care, tube feeding management, and food procurement.
A resident with acute respiratory failure was ordered to receive oxygen at bedtime, but was observed receiving it continuously. Interviews confirmed the resident had been on oxygen day and night since readmission, and the DON acknowledged the need for order clarification, indicating a failure to meet nursing standards.
The facility did not monitor medication refrigerator temperatures on the 300/400/500 unit, as required by its policy. Observations showed no evidence of daily temperature checks from July 2022 to May 2024, despite the presence of medications needing specific storage conditions. Interviews confirmed the lack of documentation for temperature monitoring.
The facility did not maintain sanitary conditions during food service as dietary aides were observed with improperly worn hair nets, allowing hair to touch their necks. This was against the facility's policy requiring full hair coverage to prevent contamination, as confirmed by the Dietary Manager.
A resident's code status was not clarified, resulting in conflicting DNR and full code orders in their medical chart. A nurse was uncertain about the correct status, and the DON acknowledged the need for clarification to ensure proper emergency response.
A facility failed to document the flushing of a PICC line with normal saline before and after administering IV antibiotics to a resident with osteomyelitis, as per their policy. This deficiency was confirmed by the DON.
The facility failed to include a resident's immediate care needs in the baseline care plan within 48 hours of admission. The resident, diagnosed with muscle wasting, Parkinson's disease, and altered mental status, had prescribed antipsychotic and antianxiety medications that were not documented in the care plan. This was confirmed by the DON.
The facility failed to develop discharge care plans for three residents, despite their policy requiring comprehensive care plans. The residents were discharged with home health services and follow-up care instructions, but there was no documented evidence of a care plan for discharge planning.
Call Bell System Unplugged and Not Reported on One Nursing Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure the call bell system on one nursing unit (100 unit) remained functional and that problems with the system were reported and addressed in accordance with facility policy and professional standards of practice. The facility’s policy on call bells required staff to report problems with the call system immediately to a supervisor or maintenance director and to provide immediate or alternative solutions until the problem was remedied, with the system set to alert staff directly or at a centralized work area. Contrary to this policy, one nurse admitted in a witness statement to unplugging the call bell monitor from the wall on a morning shift because it was “super loud,” leaving it unplugged long enough to receive report before plugging it back in. The Nursing Home Administrator confirmed that this nurse did unplug the call bell system at the nurse’s station on the 100 hall and should not have done so. Additional staff were aware of the call bell system being unplugged but did not report it to a supervisor as required. One LPN stated that another LPN told her on two separate occasions that she unplugged the call bell system during her 6–10 shift and plugged it back in before leaving, with no evidence this was reported to a supervisor. A maintenance employee reported hearing the same LPN say the call bell system was “driving her nuts” and witnessed her unplug it from the wall at a specific time, again with no evidence this was reported. Another LPN, upon returning to the 100 unit after receiving report on another unit, observed that the call bell monitor was not in its usual place and found it unplugged on the desk; she plugged it back in and reported this to the Assistant DON. The survey findings concluded that the call bell system on the 100 unit had been unplugged at the nurse’s station, and that multiple staff members were aware of this but failed to report it, placing residents at risk for potential harm.
Failure to Report Alleged Staff-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the state agency as required by its own abuse, neglect, and exploitation policy and state regulations. The facility policy defined abuse, including verbal abuse, and required that all alleged violations be reported to the Administrator, state agency, Adult Protective Services, and other required agencies within specified timeframes. Resident 4, who had hemiplegia following a stroke, aphasia, dementia, and required staff assistance for daily care, was usually able to understand and be understood. A grievance decision report documented that the resident’s daughter reported the resident had used hand gestures indicating that a nurse was rough when rolling him and told him to “shut up.” The daughter stated the resident, who does not communicate well, repeatedly said “shut up” sixteen times and referenced “night shift, heavy set, older,” and that the incident likely occurred between a Saturday night and the following Tuesday. The facility’s internal grievance investigation noted that an LPN recalled the resident telling her about someone being rough and that the resident described the staff member as having dark hair. The Assistant Director of Nursing identified this night-shift nurse as LPN 1 and stated that LPN 1 reported the resident only said someone was rough with him and did not mention being told to “shut up.” The Social Worker reported that the daughter relayed the allegation the evening before the resident’s planned discharge, and that she and the Assistant Director of Nursing took notes and developed a suspicion about who the alleged perpetrator might be based on the description and staff interviews, but could not positively identify the individual. Administration was aware of the allegation on January 27, 2026, but the resident was not interviewed about the allegation before discharge, and the allegation was never reported to the Department of Health. The Assistant Director of Nursing confirmed that LPN 1 did not immediately report the allegation as required and that the facility failed to report the allegation to the state.
Failure to Attempt Non-Pharmacological Interventions Before Administering Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically Ativan, for two residents who were cognitively impaired and dependent on staff for care. Both residents had physician orders requiring that non-pharmacological interventions be attempted and documented prior to administering anti-anxiety medication. However, review of the Medication Administration Records (MAR) for both residents over several months showed multiple instances where Ativan was administered without any documented evidence that non-pharmacological interventions were attempted beforehand. Clinical records and staff interviews confirmed that, despite facility policy and physician orders, staff did not attempt or document non-pharmacological interventions prior to administering Ativan to these residents. This was further corroborated by the Nursing Home Administrator, who acknowledged that such interventions were not attempted before medication administration on the identified dates and times.
Failure to Provide Required Transfer Notifications and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers to the hospital for three residents. Specifically, there was no documented evidence that written notification of transfer was provided to the residents or their representatives, no evidence that a bed-hold notice was given to the responsible parties, and no evidence that the ombudsman was notified of the transfers, as required by facility policy and regulation. These deficiencies were identified through review of policies, clinical records, and staff interviews. The residents involved had significant medical needs at the time of transfer. One resident, who was cognitively intact and required assistance for all daily care needs, was transferred due to involuntary jerking movements, lethargy, and increased leg swelling. Another resident, also cognitively intact and requiring minimal assistance, was transferred after a fall resulting in a forehead bruise and subsequent hospital admission for anemia, hematoma, gastrointestinal bleed, and diverticulosis. The third resident, who was cognitively impaired and required maximum assistance, was transferred due to coughing up blood and rectal bleeding. In each case, the required notifications and documentation were not completed.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident, the MDS indicated that no antibiotic was received during the seven-day look-back period, despite the Medication Administration Record (MAR) showing administration of Metronidazole. Another resident's MDS assessment failed to record the use of an antianxiety medication, even though the MAR documented administration of Ativan during the relevant period. A third resident's admission MDS did not reflect the receipt of IV antibiotics, although the MAR confirmed administration of Ceftriaxone intravenously within the look-back period. Additionally, a fourth resident's annual MDS assessment did not indicate the administration of an anticonvulsant, an antidepressant, or an antianxiety medication, despite physician orders and the MAR confirming that Topiramate, Wellbutrin, and Buspirone were given during the seven-day look-back period. These discrepancies were confirmed through review of clinical records and staff interviews, including confirmation by the Nursing Home Administrator that the MDS assessments for these residents were coded inaccurately.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident with an indwelling urinary catheter. According to facility policy, staff are required to ensure urinary catheter bags are covered to prevent demeaning exposure. During an observation, a resident was found lying in bed with her urinary drainage bag uncovered and visible from the doorway, with yellow urine clearly seen in the bag. Staff interviews confirmed that the privacy cover was not in place, and the Nursing Home Administrator acknowledged that this was not in accordance with facility policy. The deficiency was identified through review of policies, clinical records, direct observation, and staff interviews.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident, as required by its policy and state regulations. Multiple observations over several days revealed that the wall directly behind the resident's bed had approximately 20 black and white gouges in the drywall, varying in length from eight to 22 inches and covering an area about 30 inches wide. These gouges were visible upon entering the room and were not addressed prior to the survey. The resident involved was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and diabetes. The Director of Maintenance was unaware of the condition of the wall and explained that previous headboards with bolts likely caused the damage when the bed was moved. The Director of Nursing confirmed that the drywall should have been free of such damage, but it was not.
Failure to Adhere to Physician's Orders for Acetaminophen Administration
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician's orders for one resident. The physician had ordered that the resident receive 1000 mg of Acetaminophen by mouth three times daily for pain, with an additional order for 650 mg of Acetaminophen by mouth every 4 hours as needed for pain, not to exceed a total of 3,000 mg in a 24-hour period. Examination of the Medication Administration Record (MAR) for August and September 2025 showed that the resident was administered 3,650 mg of Acetaminophen on two separate days, exceeding the prescribed maximum daily dosage. The DON confirmed that the resident's Acetaminophen dose surpassed the 24-hour limit on the specified dates.
Failure to Apply Wheelchair Leg Rests During Resident Transport
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and required staff assistance for daily care due to abnormalities of gait and mobility, was transported in a wheelchair without the required leg rests in place. The resident's physician had ordered that wheelchair leg rests be used to secure the resident's feet during transport. On observation, a registered nurse transported the resident down the hallway to the activity room without applying the leg rests. The nurse confirmed at the time that the leg rests should have been used, and the Nursing Home Administrator also confirmed that the leg rests were required as ordered.
Failure to Provide and Document Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. According to the facility's policy and the resident's care plan, staff were required to perform foley catheter care and monitor urinary output every shift. Physician's orders also specified that catheter care should be completed every shift. However, a review of the resident's Treatment Administration Records for two consecutive months showed no documented evidence that catheter care was performed or that urinary output was monitored as required. The Nursing Home Administrator confirmed that these tasks should have been completed and documented, but they were not.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to physician orders and proper documentation. For one resident with chronic obstructive pulmonary disease who was dependent on staff for daily care, physician orders required weekly cleaning of the oxygen concentrator and filter, and changing of the oxygen tubing and humidifier every seven days. However, observations revealed that the oxygen concentrator and filter had a thick removable substance, and the tubing and humidifier were dated from a previous week, indicating they had not been cleaned or changed as documented in the treatment administration record. The Director of Nursing confirmed that the equipment was not maintained as required, despite documentation stating otherwise. For another resident with pleural effusion and atrial fibrillation, nursing notes indicated the resident developed respiratory symptoms and was subsequently observed receiving oxygen at 2 liters per minute via nasal cannula. Despite ongoing administration of oxygen, there was no physician order for this therapy in the resident's clinical record. The Nursing Home Administrator confirmed that oxygen was being administered without a physician's order, contrary to facility policy and regulatory requirements.
Failure to Timely Address Pharmacy GDR Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy consultant's recommendation regarding a resident's medication regimen. Specifically, a pharmacist recommended a Gradual Dose Reduction (GDR) for a resident's 25mg Zoloft prescription in May 2025, but there was no documented evidence that the physician addressed this recommendation until August 2025. Facility policy requires that such recommendations be addressed prior to the next monthly medication review, and a summary of all recommendations is to be provided to the DON and Medical Director each month. The resident involved was cognitively intact, required partial staff care, and was receiving an antianxiety medication at the time of the deficiency. This lapse was confirmed by the Nursing Home Administrator during an interview.
Expired Medical Supplies and Improper Medication Labeling in Medication Room
Penalty
Summary
Surveyors found that the facility failed to comply with its own policies and federal regulations regarding the storage and labeling of drugs and biologicals in one of two medication rooms reviewed. Specifically, 47 blood collection sets and three blood collection tubes were found to be expired but still available for use by staff. Additionally, a vial of Tubersol, a medication used for tuberculosis testing, was open and not labeled with the date it was first accessed, contrary to the package insert instructions requiring disposal 30 days after opening. These findings were confirmed through staff interviews, including with an LPN and the Nursing Home Administrator, who acknowledged that expired supplies should not be in circulation and that opened vials should be properly dated.
Failure to Follow Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in two key areas. First, the dietary director was observed in the kitchen, where food was being plated, without wearing a beard guard, despite the facility's policy requiring all dietary staff to wear hair restraints, including beard coverings, to prevent hair from contacting food. The dietary director stated that he only wears a beard guard when cooking and not when in the food preparation area. The nursing home administrator confirmed that the dietary director should have had his beard fully covered during food handling activities. Additionally, food items stored in one of the nursing unit pantry refrigerators were not labeled according to professional standards. Specifically, two open containers of macaroni salad and one open container of coleslaw were found without names or dates. An LPN and the dietary director both confirmed that food stored in residents' refrigerators should be labeled with the resident's name and the date. These findings indicate a failure to follow established policies and professional standards for food storage and personal hygiene in food service.
Incomplete Documentation of Enteral and Pleasure Feeds
Penalty
Summary
The facility failed to ensure that clinical records for a resident who was cognitively impaired and required substantial assistance were complete and accurately documented. The resident was receiving enteral nutrition via PEG tube feedings, as well as pleasure feeds. A review of nurse aide documentation for multiple dates revealed missing entries for both PEG feeds and the amount of pleasure feeds consumed across various shifts. In several instances, 'Not applicable' (NA) was documented instead of the required information, and on other occasions, there was no documentation at all for the provision of these feeds. Interviews with the Registered Dietician and the Nursing Home Administrator confirmed that the resident was receiving both tube and pleasure feeds, but staff were not consistently documenting this care in the clinical record as required. The lack of documentation was identified through a review of clinical records and staff interviews, and it was acknowledged that the amounts of tube and pleasure feeds should have been recorded in the resident's chart.
Repeated QAPI Failures in Addressing Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve care and services were effectively implemented. Despite developing plans of correction after previous surveys, the facility continued to have repeated deficiencies in several areas, including maintaining a safe, clean, and homelike environment, completing accurate Minimum Data Set (MDS) assessments, properly labeling and storing drugs and biologicals, and ensuring proper food procurement. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were identified in subsequent surveys, indicating that the committee did not successfully implement or sustain corrective actions. Specific deficiencies cited in the current survey included issues under F584 (environment), F641 (MDS assessments), F761 (labeling and storage of drugs and biologicals), and F812 (food procurement). The facility's previous plans of correction for these areas involved conducting audits and reporting findings to the QAPI committee, but the recurrence of these deficiencies demonstrates that these actions were not effective in achieving ongoing compliance with regulatory requirements.
Failure to Provide Consistent Pressure Ulcer Prevention Care
Penalty
Summary
A resident who was cognitively intact and required maximum staff assistance was admitted with a Stage 1 pressure ulcer. The resident's care plan specified that barrier cream should be applied to the buttocks three times daily to prevent further skin breakdown. However, clinical record review revealed multiple instances over a two-week period where there was no documented evidence that the barrier cream was applied as ordered during various shifts. Subsequently, the resident developed a Stage 2 pressure wound on the left buttock. The DON confirmed the lack of documentation for the application of barrier cream on the specified dates and times, which was required to prevent further skin breakdown.
Failure to Obtain Physician's Orders for Catheterization Procedures
Penalty
Summary
Nursing staff failed to follow physician's orders regarding the use of urinary catheters for a resident. The facility's policy requires that nursing staff review and obtain a physician's order prior to inserting an indwelling urinary catheter or performing a straight catheterization to obtain a urine sample. However, documentation revealed that an indwelling urinary catheter was inserted for urinary retention without evidence of a physician's order. Additionally, urine samples were obtained via straight catheterization on two separate occasions without documented physician's orders for these procedures. The resident involved was cognitively intact and required staff assistance for daily care needs, as indicated by a recent Minimum Data Set (MDS) assessment. The Director of Nursing confirmed that staff did not obtain the necessary physician's orders prior to performing these catheterization procedures, which is not in accordance with facility policy and regulatory requirements.
Failure to Properly Date, Label, and Secure Food in Resident Refrigerators
Penalty
Summary
The facility failed to ensure that food stored in residents' refrigerators and freezers was properly dated, labeled, and secured, as required by its own food safety policy. During observations of the 100-hall and 500-hall kitchenettes, surveyors found multiple opened and undated or unlabeled food items, including containers of chicken broth, pickles, milk, raspberry ice tea, thickened apple juice, macaroni and potato salad, and chicken chunks in the 100-hall kitchenette, as well as pints and quarts of vanilla ice cream in the 500-hall kitchenette. Some items, such as the chicken chunks and a quart of ice cream, were also found open to the air. The DON confirmed that all items should have been secured, dated, and labeled according to facility policy.
Failure to Conduct RN Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that an assessment was completed by a registered nurse after an injury occurred to a resident. According to the Pennsylvania Code and the facility's policy, a registered nurse is required to assess any injuries following an incident, such as a fall. However, in the case of Resident 2, who was moderately cognitively impaired and required supervision for ambulation and transfers, there was no documented evidence of a registered nurse assessment after the resident fell on December 6, 2024. The fall occurred when the resident attempted to sit in front of the piano but missed the stool and landed on the floor. Licensed Practical Nurse 2, who witnessed the fall, confirmed that no registered nurse assessment was conducted. The Director of Nursing also confirmed the lack of documentation for a registered nurse assessment and attributed the oversight to staffing shortages, as she had been covering shifts in addition to her regular duties. This failure to conduct a proper assessment by a registered nurse after the fall was a violation of the professional standards required by the facility's policies and state regulations.
Plan Of Correction
Resident 2 suffered no ill effects as a result of failure to document the Registered Nurse assessment. Education for Registered Nurses and Licensed Practical Nurses will be conducted on 1/14/2025 regarding documentation of the Registered Nurse assessment. Review of change in condition will occur during the clinical portion of the Interdisciplinary Team meeting to ensure appropriate registered nurse assessments occurred appropriately and timely. Weekly audits for accuracy by the Director of Nursing or designee will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.
Incomplete Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident, identified as Resident 3, who was involved in a fall incident. According to the facility's policy on accidents and incidents, falls require an incident report to be completed within 24 hours, including documentation of the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and follow-up interventions. However, a review of Resident 3's clinical record revealed no documented evidence of the fall or an assessment by a registered nurse, despite the fall investigation conducted by a Licensed Practical Nurse (LPN) indicating that the resident fell backwards onto her buttocks in the bathroom doorway. Resident 3, who was severely cognitively impaired with diagnoses including Alzheimer's disease and wandering behaviors, required supervision and assistance with various activities of daily living. The LPN involved in the fall investigation confirmed that she and the registered nurse on duty assessed Resident 3 following the fall but did not document an additional nursing note in the clinical record. The Director of Nursing also confirmed the absence of documentation regarding the fall and the necessary assessment by a registered nurse, which was required by the facility's policy.
Plan Of Correction
Resident 3 suffered no ill effects as a result of failure to document the incident and accident or failure to conduct the Registered Nurse assessment. Education for Registered Nurses and Licensed Practical Nurses will be conducted on 1/14/2025 regarding documentation of the incidents and accidents and documentation of the Registered Nurse assessment. Review of change in condition will occur during the clinical portion of the Interdisciplinary Team meeting to ensure documentation of incidents and accidents and the registered nurse assessments occurred appropriately and timely. Weekly audits for accuracy by the Director of Nursing or designee will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift and one NA per 15 residents during the overnight shift for several days in December 2024. On December 19 and 28, the facility's census required 7.10 and 6.50 NAs respectively during the day shift, but only 6.47 and 5.63 NAs were provided. Similarly, on December 15, 19, 20, and 21, the overnight shifts required 4.47, 4.73, 4.80, and 4.73 NAs respectively, but the facility provided only 3.24, 4.38, 4.29, and 4.22 NAs. The deficiency was confirmed through a review of nursing schedules, staffing information, and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required staffing ratios on the specified days. No additional higher-level staff were available to compensate for these deficiencies, indicating a failure to ensure adequate staffing levels to meet regulatory requirements.
Plan Of Correction
The facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. The facility will continue to take measures to adequately provide staff to meet the required nurse aide to resident ratios on all shifts. The Director of Nursing or designee will provide re-education on minimum staffing ratios to Registered Nurse Supervisors, Human Resources, and Scheduling who are responsible to maintain adequate staffing and staffing ratios. The Director of Nursing or designee will re-educate Human Resources, Scheduler and Registered Nurse supervisors of protocols for calling in staff related to call offs. The Director of Nursing or designee will audit the daily schedules to ensure that the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed after a call off occurred. These audits will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.
LPN Staffing Deficiency on Evening Shifts
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on two occasions during the evening shift between December 8 and 28, 2024. On December 20, 2024, the facility had a census of 72 residents, necessitating 2.40 LPNs, but only 2.14 LPNs were available. Similarly, on December 28, 2024, with a census of 65 residents requiring 2.17 LPNs, only 2.13 LPNs were present. The facility did not have additional higher-level staff to compensate for these deficiencies. This was confirmed in an interview with the Nursing Home Administrator on December 30, 2024.
Plan Of Correction
The facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. The facility will continue to take measures to adequately provide staff to meet the required Licensed Practical Nurse to resident ratios on the day shift. The Director of Nursing or designee will provide re-education on minimum staffing ratios to Registered Nurse Supervisors, Human Resources, and Scheduling who are responsible to maintain adequate staffing and staffing ratios. The Director of Nursing or designee will re-educate Human Resources, Scheduler and Registered Nurse supervisors of protocols for calling in staff related to call offs. The Director of Nursing or designee will audit the daily schedules to ensure that the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed after a call off occurred. These audits will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.
Facility Fails to Maintain Homelike Environment Due to Unsanitary Practices
Penalty
Summary
The facility failed to provide a clean and homelike environment as observed by surveyors. On multiple occasions, five-gallon buckets containing old food scraps were found in various hallways and lounge areas. Specifically, on August 12, 2024, a bucket was observed in the lounge area on the 400 hall, and on August 14, 2024, similar buckets were found in the 300, 400, and 500 halls. These buckets were used by staff to scrape leftover food from residents' plates, and they were left uncovered, creating an unsanitary and unpleasant environment for residents and visitors. Interviews with staff, including a nurse aide and a registered nurse, revealed that the practice of scraping plates into buckets in hallways and lounge areas was directed by the administration. The nurse aide expressed that the buckets were embarrassing and that family members had complained about them. The Assistant Director of Nursing and Infection Preventionist confirmed that this practice was not homelike, acknowledging the deficiency in maintaining a clean and comfortable environment for residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the ombudsman regarding hospital transfers, as required by their policy. This deficiency was identified for five residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated December 1, 2024, mandates written notification upon hospital transfer, but this was not adhered to for Residents 4, 7, 14, 41, and 69. Each of these residents was transferred to the hospital for various medical reasons, including pulmonary edema, hypercarbia, unresponsiveness, head laceration, and urinary retention, yet there was no documented evidence of written notification to the resident representatives or the ombudsman. Resident 4, who was cognitively intact, was transferred due to pulmonary issues, while Resident 7, who was cognitively impaired, was transferred after becoming unresponsive. Resident 14, also cognitively impaired, was transferred for unresponsiveness, and Resident 41, severely cognitively impaired, was transferred following a head injury. Resident 69, cognitively intact, was transferred due to abdominal pain and urinary retention. The Director of Nursing confirmed the lack of documentation for these notifications, which is a violation of the facility's policy and resident rights as per 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans to reflect changes in care needs for five residents. Resident 4, who was cognitively intact and had diagnoses including congestive heart failure and chronic respiratory failure, had a physician's order for a fluid restriction that was not reflected in her care plan. The Director of Nursing confirmed that the care plan should have been updated to include this restriction. Resident 29, who was severely cognitively impaired with a diagnosis of dementia with Lewy bodies, experienced an elopement incident that was not addressed in her care plan. Despite a nursing note documenting the incident, there was no evidence of revised interventions to prevent further elopements. The Director of Nursing acknowledged that the care plan should have been updated to include such interventions. Resident 38, who was cognitively intact and had a diagnosis of atrial fibrillation, had a physician's order to discontinue Pradaxa, a blood thinner, which was not updated in the care plan. Similarly, Resident 41, with severe cognitive impairment and a history of elopement, had a physician's order for a wanderguard that was not reflected in the care plan. Lastly, Resident 63, who was cognitively impaired and had episodes of sobbing, had a physician's order for Ativan for anxiety that was not included in her care plan. The Director of Nursing confirmed these omissions.
Failure to Obtain Physician's Orders for Tube Feeding Care
Penalty
Summary
The facility failed to obtain necessary physician's orders for the care and services related to tube feedings for Resident 81, who was admitted with a diagnosis of quadriplegia and required a feeding tube. The resident's clinical record lacked documented evidence of orders for NPO status, verification of feeding tube placement prior to administration of feedings, flushes, and medications, and for flushing the feeding tube between and after medication administration. Additionally, there were no orders addressing the resident's need for tube feeding care. Observations revealed that Resident 81 was receiving tube feedings via a feeding pump at a rate of 250 ml per hour, despite the absence of documented orders for this method of administration. Interviews with staff confirmed that the resident sometimes requested feedings by pump due to discomfort with bolus feedings, but no orders were obtained to reflect this preference. The Assistant Director of Nursing confirmed the lack of necessary orders for the resident's feeding tube care and administration methods.
Failure to Assist Resident in Formulating Advance Directive
Penalty
Summary
The facility failed to ensure that a resident and/or their representative had the opportunity to develop or be assisted in formulating an advance directive. This deficiency was identified during a review of clinical records and staff interviews, specifically concerning one resident. The resident in question was cognitively impaired, had absence of speech, and was dependent on care due to conditions such as hemiplegia, hemiparesis, cerebral infarction, and aphasia resulting from a stroke. Despite these conditions, the resident's Minimum Data Set (MDS) assessment indicated no impairment in short and long-term memory and only some difficulty in decision-making in new situations. The review of the resident's medical records revealed a lack of documented evidence that the resident and/or her representative was informed of their rights to develop advance directives. There was also no documentation showing that the resident and/or her representative was provided the opportunity and assistance to formulate an advance directive. Furthermore, there was no evidence that advance directives were addressed with the resident and/or her representative periodically throughout her stay. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged the absence of such documentation in the resident's medical records.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was placed on hospice services due to a terminal prognosis of heart failure. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a significant change MDS assessment should be completed no later than 14 days from the date the significant change is identified. However, there was no documented evidence that this assessment was completed for the resident after the initiation of hospice services. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Case Management.
Inaccurate MDS Assessments for Alarm Use and Wandering Behavior
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 care needs. For one resident, physician's orders indicated the use of a wanderguard alarm, and the Treatment Administration Records (TAR) confirmed its use throughout June 2024. However, the quarterly MDS assessment inaccurately coded the use of the alarm as zero, indicating it was not used. Similarly, another resident had physician's orders for a wanderguard alarm, and the TAR confirmed its use during the assessment period. Yet, the admission MDS assessment also inaccurately coded the use of the alarm as zero. Additionally, the facility failed to accurately document wandering behavior for one of the residents. A nursing note detailed an incident where the resident was found outside the building and subsequently fitted with a wanderguard bracelet. Despite this documented wandering incident, the admission MDS assessment inaccurately coded the resident's wandering behavior as zero, indicating no such behavior was exhibited. The Director of Case Management confirmed the inaccuracies in the MDS assessments for both residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, as required by their policy dated December 1, 2023. Resident 15, who is cognitively intact and has a right below-the-knee amputation, was observed using a prosthetic leg daily. However, there was no documented care plan addressing her needs related to the prosthetic leg. This was confirmed by the Assistant Director of Nursing during an interview. Resident 59, also cognitively intact, required assistance with toileting and hygiene due to frequent urinary and occasional bowel incontinence. Despite documented episodes of incontinence in July and August 2024, there was no care plan developed to address these needs. Similarly, Resident 285, who has a cardiac pacemaker and was prescribed anticoagulant and antiplatelet medications, lacked a care plan for managing these medications. The absence of care plans for these residents was confirmed by the Assistant Director of Nursing.
Failure to Clarify Physician's Orders for Medications and Devices
Penalty
Summary
The facility failed to clarify and obtain physician's orders for three residents, leading to deficiencies in medication administration and therapeutic device usage. Resident 11, who was cognitively impaired and had a feeding tube, had physician's orders for medications to be administered orally, despite instructions indicating they should be given through the feeding tube. This discrepancy was confirmed by the Assistant Director of Nursing. Similarly, Resident 59, who also had a feeding tube, had orders for oral administration of medications, which should have been clarified to reflect administration via the feeding tube. Resident 81, diagnosed with quadriplegia, had discharge orders from the hospital to wear bilateral PRAFO boots, but there was no documented evidence that these orders were clarified or implemented upon admission to the facility. Additionally, Resident 81 was observed wearing a left wrist cock-up splint, which was not documented in the clinical record as ordered. The Director of Nursing confirmed that the orders for the PRAFO boots were missed and that there were no orders for the wrist splint, indicating a failure in ensuring proper documentation and adherence to physician's orders.
Failure to Conduct Physical Assessment After Resident Elopement
Penalty
Summary
The facility failed to perform a physical assessment after an elopement incident involving Resident 29, who was one of 32 residents reviewed. According to the facility's policy on elopements and wandering residents, a registered nurse is required to conduct a physical assessment upon the resident's return and document and report the findings to the physician. Resident 29, who was severely cognitively impaired and diagnosed with dementia with Lewy bodies, eloped from the facility on December 29, 2023. The nursing note indicated that the resident was found outside in a fenced-in area after the door alarms went off. However, there was no documented evidence that a physical assessment was conducted by a registered nurse, nor were the findings reported to the physician. The Director of Nursing confirmed that the assessment was not completed as required.
Failure to Follow Fluid Restriction and Weight Monitoring Orders
Penalty
Summary
The facility failed to adhere to physician's orders regarding fluid restrictions and weight monitoring for a resident. The resident, who was cognitively intact and required assistance with care needs, had diagnoses including congestive heart failure, chronic respiratory failure, and chronic obstructive pulmonary disease. The physician's orders specified a daily fluid restriction of 2,000 cc, with specific allocations from dietary and nursing departments. However, a review of the Medication Administration Record (MAR) for several months revealed no documented evidence that the fluid restriction was being followed or recorded as per the physician's orders. Additionally, the physician's orders required the resident to be weighed every other day in the morning. A review of the Treatment Administration Record (MAR) showed that weights were not obtained on several specified dates across June, July, and August. An interview with the Director of Nursing confirmed the lack of documentation for both the fluid restriction and the weight monitoring as per the physician's orders.
Failure to Implement Non-Pharmacological Interventions Before Administering Ativan
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not attempting non-pharmacological interventions before administering as-needed antianxiety medications. Specifically, for one resident with Alzheimer's disease, dementia, and depression, the facility did not document any non-pharmacological interventions prior to administering Ativan for sobbing and anxiety. The facility's policy required such interventions to be attempted and documented, but this was not followed. The resident's physician's orders included multiple adjustments to the Ativan dosage over a period of time, yet there was no evidence of non-pharmacological interventions being attempted before each administration. The Medication Administration Record showed numerous instances of Ativan being given without prior non-pharmacological attempts, which was confirmed by the Assistant Director of Nursing. This oversight was a violation of the facility's policy and regulatory requirements.
Improper Security of Emergency Narcotic Medications
Penalty
Summary
The facility failed to ensure that emergency controlled medications, specifically narcotics, were properly secured in the medication room. According to the facility's policy dated December 1, 2023, narcotic medications should be stored behind a double lock and secured in a narcotics box within the refrigerator. However, observations on August 12, 2024, revealed that the emergency narcotic medications were stored in an unsecured refrigerator, making them easily accessible. This was confirmed during an interview with a registered nurse, who acknowledged that the refrigerator containing the narcotic box was not secured. Further confirmation came from the Assistant Director of Nursing, who admitted that the emergency narcotic medications should have been secured in the refrigerator but were not.
Failure to Maintain Proper Beverage Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as evidenced by observations and interviews. The facility's policy, dated December 1, 2023, mandates that foods and beverages be served in a manner that prevents contamination and maintains proper temperatures. However, on August 12, 2024, and August 14, 2024, observations on the 300 hall revealed that various beverages, including milk, juice, and iced tea, were stored on a cart without cold containers, resulting in them being warm to the touch. An interview with Nutritional Aide 5 confirmed that these drinks were intended to be placed back into the refrigerator for the next meal. The Director of Nutritional Services confirmed that the chocolate milk and cranberry juice were at temperatures of 60.0 and 57.9 degrees Fahrenheit, respectively, and acknowledged that these drinks should not have been available to residents at those temperatures.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not properly labeling and dating food items stored in their walk-in refrigerator and freezer. During an inspection, surveyors observed several food items, including an opened container of cherries, storage containers, trays of peas, pans of chicken, and breadsticks in the refrigerator, as well as a half bag of onion rings, a half bag of french fries, and a bag of pitas in the freezer, all of which were not labeled or dated. The facility's policy, dated December 1, 2023, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. An interview with the Dietary Manager confirmed that these items should have been labeled and dated, but were not, indicating a failure to comply with the facility's own food safety policies.
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 identified in the current survey ending August 14, 2024. These deficiencies were related to accurate Minimum Data Set (MDS) assessments, comprehensive and individualized care plans, adherence to professional standards, quality of care, tube feeding management, and food procurement. Despite having developed plans of correction following a previous survey ending September 21, 2023, the facility did not successfully implement these plans to maintain compliance with nursing home regulations. The facility's plans of correction included conducting audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee did not successfully implement these plans, resulting in repeated deficiencies. Specific citations included F641 for MDS assessments, F656 for care plans, F658 for professional standards, F684 for quality of care, F693 for tube feeding management, and F812 for food procurement. These findings indicate a failure in the facility's quality assurance systems to ensure compliance with the cited regulations.
Failure to Clarify Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to clarify a physician's order for a resident who was receiving oxygen therapy. The resident, who had a diagnosis of acute respiratory failure and was understood and able to understand, was admitted with a physician's order to receive oxygen at two liters per minute at bedtime for pneumonia. However, documentation and interviews revealed that the resident was receiving oxygen throughout the day and night, contrary to the physician's order. Observations and interviews confirmed that the resident had been receiving continuous oxygen since readmission, and the Director of Nursing acknowledged that the physician's order should have been clarified. This discrepancy between the physician's order and the actual care provided indicates a failure to adhere to professional standards of nursing practice as outlined in the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor medication refrigerator temperatures on one of its nursing units, specifically the 300/400/500 unit. According to the facility's policy dated December 1, 2023, all medications requiring refrigeration should be stored within 36-46 degrees Fahrenheit, with temperature levels recorded daily by the charge nurse or other designee. However, observations on May 13, 2024, revealed that there was no documented evidence of daily temperature monitoring for the two refrigerators in the 300/400/500 medication room from July 2022 to May 13, 2024. The refrigerators contained various medications, including insulin vials and pens, tuberculosis skin testing solution, pneumonia vaccination, and other medications requiring specific storage conditions. Interviews with a registered nurse and the Director of Nursing confirmed the lack of documentation for daily temperature monitoring, which is necessary to ensure medications are stored according to manufacturer's recommendations. This deficiency was noted under 28 Pa. Code 211.9(a)(1) Pharmacy Services and 28 Pa. Code 211.12(d)(1) Nursing Services.
Failure to Maintain Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as observed during a lunch meal service. The facility's policy on personal hygiene, dated December 1, 2023, mandates that all dietary staff must wear hair restraints to prevent hair from contacting food and to avoid contamination. However, during an observation in the main kitchen, it was noted that two dietary aides, while preparing and serving food, had hair nets that did not fully cover their hair, with strands touching the backs of their necks. This was confirmed in an interview with the Dietary Manager, who acknowledged that dietary staff should have their hair completely covered when working in the kitchen.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to ensure the clarification of a resident's code status, leading to a discrepancy in the medical records. The facility's policy on Physician Orders for Life Sustaining Treatment (POLST) requires that residents' preferences for resuscitation be clarified upon admission, including discussions with the physician about diagnoses, prognosis, and resuscitation status. However, for one resident with severe cognitive impairment, there was a conflict between the physician's orders and the POLST form. The physician's orders indicated a Do Not Resuscitate (DNR) status, while the POLST form in the resident's chart indicated a full code status. During interviews, a registered nurse expressed uncertainty about the resident's correct code status due to the conflicting information in the chart. The Director of Nursing acknowledged that the resident's code status should have been clarified to ensure only one status was documented, allowing staff to respond appropriately in an emergency. This lack of clarification could lead to confusion among staff regarding the appropriate actions to take in the event of a cardiac arrest.
Failure to Document PICC Line Flushing
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids through a peripherally-inserted central catheter (PICC) line for one of the residents reviewed. According to the facility's policy on intravenous administration, the PICC line should be flushed with 10 milliliters of normal saline before and after each administration of medication. However, for a resident who required intravenous antibiotics for osteomyelitis of the left foot, there was no documented evidence that the PICC line was flushed as per the policy. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation for the required flushing procedure.
Failure to Include Immediate Care Needs in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs within 48 hours of admission. Specifically, for one resident with diagnoses of muscle wasting, Parkinson's disease, and altered mental status, the baseline care plan did not document the need for antipsychotic or antianxiety medications as prescribed by the physician. This omission was confirmed by the Director of Nursing during an interview. The facility policy mandates the development of a baseline care plan within 48 hours of admission to provide effective and person-centered care, which was not adhered to in this case.
Failure to Develop Discharge Care Plans
Penalty
Summary
The facility failed to ensure that a care plan was developed for discharge planning for three residents. Resident 1 was admitted with a fractured femur and was discharged without a documented care plan for home health services and follow-up care. Similarly, Resident 4, who had a right thigh wound and chronic cellulitis, was discharged without a documented care plan for home health services and follow-up care. Resident 6, admitted with a pulmonary embolism, was also discharged without a documented care plan for home health services and follow-up care. In all three cases, the discharge plans included home health nursing, physical and occupational therapy, and follow-up with primary care physicians, but there was no documented evidence of a comprehensive care plan for discharge planning. The Director of Nursing confirmed that care plans for discharge planning were not developed for Residents 1, 4, and 6, despite the facility's policy requiring an interdisciplinary team to create and maintain comprehensive care plans. The policy emphasized the need for care plans to address identified problem areas, risk factors, treatment goals, and professional services responsible for each element of care. The lack of documented care plans for discharge planning indicates a failure to adhere to this policy, resulting in deficiencies in the discharge process for the affected residents.
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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