Bradford Manor Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bradford, Pennsylvania.
- Location
- 50 Lang Maid Lane, Bradford, Pennsylvania 16701
- CMS Provider Number
- 395700
- Inspections on file
- 17
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Bradford Manor Nursing And Rehab during CMS and state inspections, most recent first.
Heat tape installed on the building was found plugged into outlet multipliers outside the main entrance, which was confirmed as a deficiency by the maintenance supervisor during the survey.
Surveyors found two full oxygen cylinders unsecured in the oxygen storage room near the generator, in violation of NFPA gas equipment storage requirements. The maintenance supervisor confirmed the deficiency during the inspection.
Surveyors identified that three electrical receptacles in the facility were not GFCI protected as required, including those near a sink in the café, a water fountain near the nurse station, and a juice machine in the kitchen. These deficiencies were confirmed by the maintenance supervisor.
Three residents with complex medical conditions were transferred to the hospital without documentation that their necessary clinical information was communicated to the receiving health care provider, as required by federal and state regulations. The DON confirmed that the clinical records lacked evidence of this communication at the time of transfer.
The facility did not develop required person-centered care plans for two residents: one with PTSD and another requiring oxygen therapy. The absence of these care plans was confirmed by facility leadership, despite both residents having clear medical needs documented in their records.
Four residents with complex medical conditions, including COPD, hypertension, hyperlipidemia, hypothyroidism, type II diabetes, and heart failure, had care plans that were not reviewed or revised by the required target dates. The DON confirmed that these care plans were overdue and should have been updated as per facility policy.
A resident with COPD, hypertension, and heart failure did not have their oxygen tubing and humidifier bottle changed or dated as required by facility policy and physician orders. Observations showed the nasal cannula was undated and the humidifier bottle had not been changed for over a month, despite frequent oxygen use. An LPN confirmed these items should have been changed according to protocol.
Surveyors observed that a LPN did not wear a gown while providing wound care to a resident under enhanced barrier precautions, and a urinary drainage bag for another resident was repeatedly found lying on the floor with the spout touching the surface. Both staff and facility policies confirmed these actions did not meet required infection control standards.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for residents with indwelling medical devices, such as gastric feeding tubes and urinary catheters, during high contact care activities. Despite physician orders for daily care, observations revealed that EBPs were not in place, and the Director of Nursing confirmed that staff should have been using gloves and gowns. This deficiency affected multiple residents with various medical conditions.
A facility failed to ensure consistency between a resident's physician's orders, POLST, and care plan. The resident, with conditions including end-stage renal disease and Parkinson's disease, had a DNR order, but the POLST requested CPR and comfort measures only. The care plan also indicated DNR, leading to a discrepancy confirmed by the Nursing Home Administrator.
A facility failed to accurately complete the MDS for a resident with hemiplegia and other conditions. The Quarterly MDS incorrectly coded a fall with a major injury, despite the resident being found on the floor with a bruise and not requiring hospital treatment. This error was confirmed by the Nursing Home Administrator.
A resident with hemiplegia did not receive physician-ordered treatment for range of motion maintenance, as their hand splint was repeatedly observed off the resident and on the nightstand. An LPN confirmed the splint should have been worn except during hygiene, indicating a failure to follow the care plan.
A resident with a history of pneumonia, anxiety, COPD, and chronic respiratory failure was observed receiving oxygen at 4 lpm, contrary to the physician's order of 3 lpm PRN. This discrepancy was confirmed by an LPN, indicating a failure to follow the care plan and physician's orders for respiratory care.
A facility failed to document a clinical rationale and duration for a PRN psychotropic medication beyond 14 days for a resident with anxiety and other health issues. The medication order for Hydroxyzine lacked a required stop date or justification for continued use, as confirmed by a registered nurse.
Improper Use of Outlet Multipliers for Heat Tape
Penalty
Summary
The facility failed to maintain electrical system requirements in one of four smoke compartments. During an observation, heat tape installed on the building was found to be plugged into outlet multipliers located outside the main entrance. This setup was directly observed by surveyors, and the maintenance supervisor confirmed the deficiency at the time of the survey. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance. Education was provided to the Maintenance department by the Nursing Home Administrator regarding safety concerns with using outlet multipliers and its unacceptable practice. Heat tape was unplugged from outlet multiplier on day of survey. All other areas where heat tape is used were checked to ensure that no outlet multipliers were being used, none were identified. Ongoing compliance will be monitored through daily rounding by the Environmental Service Supervisor or designee 3x weekly for 2 weeks.
Unsecured Oxygen Cylinders in Storage Room
Penalty
Summary
During an inspection, surveyors observed that the oxygen storage room, located near the generator, contained two full oxygen cylinders that were not properly secured. This observation was made on August 5, 2025, at 11:02 a.m. The facility is required to maintain gas equipment in accordance with NFPA 101 and NFPA 99 standards, which include securing cylinders to prevent them from falling or being damaged. The maintenance supervisor was present during the observation and confirmed that the two full cylinders were unsecured at the time of the survey. The deficiency was identified based on the direct observation of the unsecured cylinders in the designated storage area. No additional details regarding patient involvement or medical history were provided in the report.
Plan Of Correction
Education was provided to all staff regarding the requirements of storing gas equipment. The two unsecured tanks identified during survey were immediately placed in a secured storage holder at the time of survey. Ongoing compliance will be maintained by observations during daily rounding by the Environmental Service Supervisor or designee, 3 times weekly for 2 weeks, then once weekly for 1 month.
Failure to Maintain GFCI Protection for Electrical Receptacles
Penalty
Summary
Surveyors observed that the facility failed to maintain electrical receptacles in accordance with NFPA 101 and NFPA 99 standards. Specifically, three deficiencies were identified: a receptacle in the main floor Sweet Shop café was not GFCI protected within six feet of a sink basin; a water fountain near the main floor center core nurse station was not connected to a GFCI protected receptacle; and a juice machine in the main floor kitchen was not connected to a GFCI protected receptacle. These deficiencies were confirmed during an interview with the maintenance supervisor. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Education was provided to the Maintenance department by the Nursing Home Administrator regarding the requirement of having power receptacles to have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. All identified outlets were changed over to GFCI outlets on day of survey. A whole house observation of all outlets near water sources was inspected with no others identified. Ongoing compliance will be maintained through daily rounding by the Environmental Service Supervisor or designee 3x weekly for 2 weeks. K 0912
Failure to Communicate Required Clinical Information During Resident Transfers
Penalty
Summary
Bradford Manor was found to be noncompliant with federal and state regulations regarding the discharge process, specifically the communication of necessary clinical information to receiving health care providers when residents were transferred to the hospital. The facility's policy requires sufficient preparation to ensure safe and orderly transfers, with documentation in the residents' clinical records. However, for three residents reviewed, the required information was not communicated as mandated. One resident with diabetes and chronic obstructive pulmonary disease (COPD) was transferred to the hospital, but the clinical record did not show that necessary clinical information was provided to the receiving provider. Another resident with peripheral vascular disease, hyperlipidemia, and hypertension was transferred to the hospital on two occasions, and in both instances, the clinical record lacked evidence of communication of essential clinical information to the hospital. A third resident with COPD, hypertension, and heart failure was also transferred to the hospital, and again, the clinical record did not contain documentation that the required information was shared with the receiving provider. During an interview, the Director of Nursing confirmed that the clinical records for these residents did not contain evidence that the necessary clinical information was provided to the receiving health care provider upon transfer. The facility failed to meet the requirements for ensuring that all pertinent information was communicated during resident transfers, as outlined in both federal and state regulations.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance. Contacted the hospital that a current resident is admitted to and confirmed that they have received all of the resident's medical record information as required. For the identified residents, we interviewed the nurses that transferred them out and confirmed that all required information was communicated and sent with the resident at time of transfer. Those nurses were immediately educated. The E-interact (transfer document used in our electronic health records) is processed and it includes all of the resident's medical records as well as a checklist of all required documents that are to be sent when resident is transferred. This checklist will be signed by the nurse completing the transfer and then placed in the resident's chart. Director of Nursing or designee will provide education to all registered nurses on the requirements of providing and documenting that all necessary resident information sent and communicated with the receiving healthcare provider upon transfer by 8/30/2025. DON will audit 100% of transfers for the past one month, then 50% of transfers for the past one month, and then 25% of transfers for the past one month. All findings will be reviewed at monthly Quality Assurance and Performance Improvement meetings.
Failure to Develop Comprehensive Care Plans for PTSD and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with a diagnosis of Parkinson's disease, PTSD, anxiety, and depression, the clinical record review showed that there was no care plan addressing PTSD. This omission was confirmed by the Nursing Home Administrator during an interview. For another resident with chronic obstructive pulmonary disease, hypertension, and heart failure, the review of the clinical record revealed that there was no care plan for respiratory care involving the use of oxygen, which was also confirmed by the Director of Nursing. The facility's own policy requires the development of comprehensive care plans that include measurable objectives and timetables to address each resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment. The care plans are to be developed by the interdisciplinary team and periodically reviewed and revised. In these two cases, the required care plans for PTSD and for respiratory care with oxygen were not developed, despite the residents' documented needs and diagnoses.
Plan Of Correction
Director of Nursing or Designee will provide education to the Interdisciplinary Team on the requirements of developing and implementing a comprehensive person-centered care plan for each resident reflecting their specific needs by 08/30/2025. R8's care plan was updated to reflect that he has PTSD, goals and interventions specific to him. R84's care plan was updated to reflect her respiratory plan of care. An audit of all current residents with an order for oxygen will be conducted to ensure that they have a respiratory care plan. An audit of all current residents with a diagnosis of PTSD will be reviewed to ensure that they have a person-centered care plan completed. Ongoing compliance will be maintained by the Director of Nursing or designee checking 10% of current residents' care plans weekly for one month and then 5% weekly for one month to ensure that the care plans are person-centered for each resident, including measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Findings of these audits will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Timely Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the required target dates for four residents. According to the facility's own Care Plan Policy, care plans are to be periodically reviewed and revised to ensure they reflect the current necessary care and services. However, for four residents with various diagnoses including COPD, hypertension, hyperlipidemia, hypothyroidism, type II diabetes, and heart failure, their care plans were not updated by the specified target dates. For example, one resident with a catheter had a care plan with a target date that was missed, and other residents had all their care plans overdue for revision. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plans for these residents were beyond their target dates and should have been updated accordingly. The failure to update care plans as required was identified through review of facility policy, clinical records, and staff interviews.
Plan Of Correction
Director of Nursing or Designee will provide education to the Interdisciplinary Team on the requirements of developing a comprehensive person-centered care plan within 7 days after completion of the comprehensive assessment and then ongoing review/revise after each assessment including comprehensive and quarterly reviews by 08/30/2025. Residents R4, R11, R78, and R84 had completed care plan reviews. All other residents, triggering with late review dates, will be reviewed and updated by 09/15/2025. Ongoing compliance will be maintained by the Director of Nursing or designee checking 10% of current residents' care plans weekly for one month and then 5% weekly for one month to ensure that care plans have been reviewed/revised within the target date. All findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Change and Date Oxygen Tubing and Humidifier Bottle per Policy and Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders and facility policy for a resident requiring oxygen therapy. Specifically, the facility did not change or date the oxygen tubing and humidifier bottle as required. Facility policy stated that oxygen cannulas and prefilled humidifier bottles should be changed weekly or as needed, and physician's orders directed that oxygen tubing, supply bag, and water jug be changed weekly. Review of the resident's clinical record showed frequent use of oxygen, yet observations revealed that the nasal cannula attached to the resident's oxygen tank was not dated, and the humidifier water bottle attached to the oxygen concentrator was last dated over a month prior. Further observations on multiple occasions confirmed that the nasal cannula remained undated and the humidifier water bottle had not been changed according to the required schedule. During an interview, an LPN confirmed that both the nasal cannula and humidifier water bottle should have been changed and that the current practice did not meet the facility's policy or the physician's orders. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and heart failure, and had used oxygen therapy multiple times during the review period.
Plan Of Correction
Director of Nursing or designee will provide education to all nurses on the policy of providing oxygen and changing and dating oxygen tubing and humidifier bottles according to physician's orders by 08/30/2025. The identified resident, R84, oxygen tubing and humidifier water bottle was replaced immediately. All other residents with oxygen orders had their tubing and bottles checked to ensure we were in compliance with the required changing date. Ongoing compliance will be monitored by the Director of Nursing or designee by ensuring that all residents with oxygen orders have tubing and humidifier bottles changed weekly per policy and physician order, one time per day weekly for one month, one time per day every other week for one month and then monthly for two months. All findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Follow Infection Control Protocols for Wound Care and Catheter Management
Penalty
Summary
Surveyors identified deficiencies in infection control practices related to enhanced barrier precautions (EBP) and urinary catheter care. For one resident with a diabetic foot ulcer and chronic kidney disease, a LPN performed wound care without donning a gown, despite a posted EBP sign and the availability of gloves and gowns in the room. Facility policy required the use of gloves and gowns for high-contact care activities such as wound care, but this protocol was not followed during the observed event. The LPN confirmed not wearing a gown prior to entering the resident's room. Additionally, another resident with an indwelling urinary catheter was observed multiple times with the urinary drainage bag lying flat on the floor, with the drainage spout touching the floor. Facility staff confirmed that the urinary drainage bag should not be on the floor, as per infection control standards. Both incidents were confirmed through staff interviews and direct observation, indicating a failure to adhere to established infection prevention and control policies.
Plan Of Correction
Director of Nursing or designee will provide education to all nursing staff on Infection Control and Enhanced Barrier Precautions. Education will include catheter care and placement. All education will be completed by 08/30/2025. Identified resident's, R4, catheter bag was removed from the floor immediately and staff working the hall were educated. All residents with a catheter were checked to ensure that their catheter bag was properly placed. Nurse that provided wound care was immediately educated. Resident R9 was monitored for signs and symptoms of infection for five days. Ongoing compliance will be monitored by Director of Nursing or designee by observing nursing staff following enhanced barrier requirements on 10% of residents with orders for enhanced barrier precautions one time per day 3x week for 2 weeks, one time per day weekly for 2 weeks and one time per day monthly for 2 months. Audits shall cover all shifts and all residents with orders for enhanced barrier precautions. Director of Nursing or designee will do an audit all residents with catheters will be checked to ensure the catheter bags are not placed on the floor one time per day 3x week for 2 weeks, one time per day weekly for 2 weeks and then one time per day monthly for 2 months. Audits shall cover all shifts and all residents with orders for a catheter. Findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices regarding Enhanced Barrier Precautions (EBPs) for residents with indwelling medical devices, such as gastric feeding tubes and urinary catheters. This deficiency was identified for six residents who required high contact care activities, which include device care. The facility's policy on EBPs, dated December 7, 2023, specifies that such precautions should be considered for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. However, observations on August 28, 2024, revealed that EBPs were not in place for any of the residents reviewed, despite their need for high contact care activities. The residents involved had various medical conditions, including sepsis, hypertension, chronic kidney disease, hemiplegia, neuromuscular dysfunction of the bladder, and multiple sclerosis. Physician orders for these residents included daily gastric tube site care and indwelling catheter care every shift, which are considered high contact care activities. During an interview, the Director of Nursing confirmed that employees should have been wearing gloves and gowns during these activities, but EBPs were not being followed. This oversight was noted for all six residents reviewed, indicating a systemic failure to adhere to the facility's infection control policy.
Inconsistency in Resident's Life-Sustaining Treatment Orders
Penalty
Summary
The facility failed to ensure consistency between a resident's physician's orders, Pennsylvania Order for Life Sustaining Treatment (POLST), and care plan. The resident, who was admitted with diagnoses including end-stage renal disease, Parkinson's disease, and adult failure to thrive, had a physician's order indicating Do Not Resuscitate (DNR) status. However, the POLST for the same resident requested Cardiopulmonary Resuscitation (CPR) and comfort measures only. The care plan also indicated a DNR status, creating a discrepancy between the documents. This inconsistency was confirmed during an interview with the Nursing Home Administrator.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, identified as Resident R15, which led to a deficiency. Resident R15, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, depression, heart failure, and high blood pressure, was involved in this incident. The Quarterly MDS inaccurately reflected the resident's status by incorrectly coding a fall with a major injury. The resident's progress notes indicated that on June 30, 2024, the resident was found on the floor with a bruise to the mid-back but did not require hospital treatment. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged the incorrect coding in Section J1900 of the MDS.
Failure to Implement Physician-Ordered Splint Use
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident R59, who had limited range of motion due to hemiplegia. The resident's clinical record included a physician's order for a hand splint to be worn on the left hand, which could be removed only for hygiene purposes. The care plan also specified the use of the left hand splint for contracture management. However, observations on multiple occasions revealed that the resident's left hand splint was not being used as prescribed, as it was found laying on the nightstand instead of being worn by the resident. During an interview, an LPN confirmed that the splint was not on the resident's hand and acknowledged that it should have been, except during hygiene. This oversight indicates a failure to adhere to the physician's orders and the resident's care plan, potentially leading to a further decrease in the resident's range of motion. The deficiency was identified through a review of facility policies, clinical records, and staff interviews, highlighting a lapse in the implementation of restorative care services for the resident.
Failure to Adhere to Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's orders for a resident identified as R65. The resident's clinical record indicated a physician's order for oxygen via nasal cannula at 3 liters per minute (lpm) as needed (PRN). However, observations on multiple occasions revealed that the resident was receiving oxygen at a flow rate of 4 lpm, which was not in accordance with the prescribed order. This discrepancy was confirmed during an interview with a Licensed Practical Nurse (LPN), who acknowledged that the oxygen concentrator was set incorrectly. Resident R65 had a medical history that included pneumonia, anxiety, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure, conditions that necessitate careful management of oxygen therapy. Despite the care plan specifying the correct oxygen flow rate, the facility's staff did not adhere to the physician's orders, resulting in the resident receiving a higher oxygen flow than prescribed. This failure to follow the care plan and physician's orders constitutes a deficiency in the facility's provision of respiratory care services.
Failure to Document PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident. The resident, identified as R65, was admitted with diagnoses including pneumonia, anxiety, chronic obstructive pulmonary disease, and chronic respiratory failure. A review of the resident's medication orders revealed a physician's order for Hydroxyzine, an anti-anxiety medication, to be administered every 12 hours as needed for anxiety. This order, dated 8/21/24, lacked the required stop date within 14 days or a clinical rationale for its continuation beyond this period. During an interview, a registered nurse confirmed that the Hydroxyzine order for Resident R65 did not include the necessary stop date or clinical rationale for use beyond 14 days, acknowledging that such documentation is required.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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