Broad Mountain Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Frackville, Pennsylvania.
- Location
- 500 West Laurel Street, Frackville, Pennsylvania 17931
- CMS Provider Number
- 395286
- Inspections on file
- 32
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Broad Mountain Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide adequate housekeeping and maintenance, resulting in unaddressed wall and ceiling damage, stained ceiling tiles, and unclean resident rooms with debris and spilled liquids. Residents reported inconsistent cleaning, and unsafe placement of equipment was observed. Facility leadership confirmed the environment was not maintained as required.
The facility did not provide enough nursing staff to meet resident needs, resulting in multiple falls, delayed care, missed showers, and inadequate supervision for residents requiring one-to-one monitoring. Staffing records and interviews confirmed that nurse aide and LPN ratios, as well as required nursing care hours, were not met on several dates, directly impacting residents who were dependent on staff for daily care and safety.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised despite having a wander guard bracelet and a care plan in place. Multiple door alarms were activated, but staff were unable to interpret alarm panels, repeatedly silenced alarms without confirming resident safety, and failed to conduct a headcount or initiate the Code Green procedure. The incident was not reported or investigated for over a day, and no new interventions were implemented to protect other residents at risk.
Facility administration did not ensure effective use of resources to maintain resident safety, resulting in a resident at risk for wandering exiting the building unsupervised and entering an unsafe area. Staff and leadership interviews revealed that safety measures and communication protocols were not followed, and there was confusion about monitoring responsibilities, leading to delayed identification of the incident and placing residents in immediate jeopardy.
A resident with a history of aggressive behaviors repeatedly physically abused three severely cognitively impaired residents, including incidents of hitting and hair-pulling. Despite documented patterns of aggression and orders for increased supervision such as 15-minute checks and 1:1 monitoring, staff failed to consistently implement these interventions, resulting in ongoing abuse. Facility leadership confirmed that supervision and monitoring were insufficient to prevent these incidents.
Surveyors found that several residents did not have access to their call bells, as the devices were placed on the floor and out of reach, and two residents could not access or read their room display boards due to their height. Staff confirmed these accessibility issues, and the NHA acknowledged the facility's responsibility to accommodate residents' needs.
Two residents dependent on staff for ADLs did not consistently receive scheduled showers or the necessary assistance with eating. One resident missed multiple scheduled showers without documentation of refusal or preference, while another, with severe cognitive impairment and total dependence for self-feeding, was left unattended during meals and did not have updated care plans or staff communication reflecting his needs. Staff interviews confirmed a lack of effective communication regarding required assistance, resulting in unmet hygiene and nutritional needs.
The facility did not have a qualified professional actively directing the activities program after the resignation of the previous director. Temporary coverage was provided, but the new activities director had not yet obtained required certification, and remote oversight was limited and did not fulfill regulatory requirements for assessment and care planning.
A resident with diabetes and end-stage renal disease did not receive routine blood glucose monitoring or timely physician notification of elevated glucose levels, despite being prescribed diabetes medications and having a care plan indicating risk for unstable blood sugars. The resident expressed a desire for more frequent monitoring, and documentation showed a lack of person-centered care planning and communication with the physician regarding diabetes management.
A resident with chronic pain conditions did not receive comprehensive pain assessments or appropriate documentation of pain management interventions, despite multiple complaints of severe pain and administration of both acetaminophen and oxycodone. Staff failed to document pain levels or the effectiveness of medications, and the resident reported that her pain was not understood or adequately addressed.
The facility did not follow its own smoking safety procedures, failing to complete required quarterly smoking safety assessments for three residents with chronic conditions, and omitting safe smoking interventions in one resident's care plan. The DON confirmed these lapses in assessment and care planning.
A resident's Minimum Data Set (MDS) assessment inaccurately documented the discharge status, indicating transfer to an acute hospital when the resident was actually discharged to another LTC facility. This discrepancy was confirmed by the NHA after review of clinical records and staff interviews.
A resident with bipolar disorder and diabetes was admitted and received a psychiatric consult recommending monitoring of behavioral and mood symptoms. The care plan was not updated to include assessments, goals, or interventions for bipolar disorder, and the DON confirmed the omission during interview.
A resident with multiple chronic conditions was given a one-time dose of Ceftriaxone for respiratory symptoms before lab and imaging results were available. The clinical record lacked documentation from the practitioner providing a diagnosis or clinical rationale for starting the antibiotic, and the DON confirmed no such justification was present.
Nursing staff did not promptly notify a physician of abnormal urine culture results for a resident with diabetes and a brain tumor undergoing chemotherapy, despite facility policy requiring timely communication of such findings. The abnormal result was reported two days late and only after surveyor inquiry, and there was also no documentation that required urinalysis or culture and sensitivity tests were completed as ordered.
A resident with a history of stroke and diabetes, who was cognitively intact, did not receive timely dental services after a dentist recommended multiple extractions and dentures. Despite clear recommendations for prompt treatment to prevent complications, the facility did not schedule the necessary dental procedures, and the administrator could not provide documentation or an explanation for the delay.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with moderate cognitive impairment and a history of aggressive behavior. The facility failed to assess the residents' capacity to consent to a sexual relationship, leading to a deficiency in compliance with abuse prevention policies.
A resident with severe cognitive impairment and a feeding tube experienced significant weight loss due to the facility's failure to administer enteral feedings as ordered. Despite physician orders for bolus feedings when less than 50% of meals were consumed, documentation showed multiple instances where these feedings were not provided. The resident's weight dropped significantly over a short period, and the facility delayed assessing the resident's nutritional status.
The facility failed to address resident complaints about the lack of snack variety, as expressed in group meetings. Residents reported dissatisfaction with the limited options, such as the absence of fresh fruit and repetitive snack choices. Despite raising these concerns in meetings, the facility did not take sufficient action to resolve the issues, and there was no documentation of follow-up with residents to assess the effectiveness of any efforts made.
The facility failed to ensure accurate MDS Assessments for two residents, incorrectly indicating they did not require Level II PASRR processes. Despite previous determinations confirming their need for specialized services, the assessments inaccurately reflected their status, as confirmed by the Social Services Director.
The facility failed to follow physician orders for bowel protocols for two residents, resulting in extended periods without bowel movements. One resident, with multiple diagnoses including diabetes and chronic kidney disease, did not receive the prescribed interventions for eight days and again for four days. Another resident, with end-stage renal disease and constipation, did not receive the prescribed bowel regimen for four days. The DON confirmed the staff's failure to administer the protocols and notify the physician timely.
The facility failed to provide necessary therapeutic social services for two residents, one with dementia and major depressive disorder who exhibited aggressive and inappropriate behaviors, and another with depression and PTSD who expressed a need for therapy. Despite ongoing issues, the facility did not arrange for additional behavioral health consultations or implement supportive social service interventions.
The facility failed to adhere to proper storage and use-by dates for medications and supplements. An LPN confirmed that insulin pens for two residents were beyond the recommended use-by date. In the medication storage room, a multi-dose bottle of Tuberculin and a Saw Palmetto supplement were also found to be expired. The DON confirmed these deficiencies.
The facility failed to conduct timely smoking assessments for three residents, as required by their policy. The last assessments for these residents, who have conditions such as diabetes, depression, and anxiety, were not updated according to the quarterly schedule. The Nursing Home Administrator confirmed the oversight, which violates 28 Pa. Code 209.3 (a)(c) on smoking policies.
A facility failed to complete a required PASRR Level II evaluation for a resident with a positive screen for serious mental illness, including bipolar disorder, depression, and anxiety. Despite the resident's involuntary admission for psychiatric care, the necessary evaluation was not documented, as confirmed by the social services director.
A facility failed to create and implement a person-centered care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. This deficiency was confirmed by the Nursing Home Administrator, who admitted the facility's inability to provide culturally competent, trauma-informed care according to professional standards.
A facility failed to provide a resident with the required advance notice of Medicare non-coverage. The resident received a Notice of Medicare Non-Coverage (CMS 10123-NOMNC) with incorrect dates, indicating services would end later than they actually did. This discrepancy was confirmed by the Nursing Home Administrator.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's housekeeping and maintenance services, resulting in an environment that was not consistently safe, clean, or homelike. On the first floor, a large hole was found in the wall near the toilet in the shower room, and a ceiling tile was missing in front of the privacy curtain. On the second floor, a ceiling tile near the nurses station had a 4-inch brown stain with black discoloration, and three ceiling tiles in the dining room had large brown stains resembling water damage. In resident rooms, there were significant cleanliness issues, including a used rubber glove, a used plastic cup, a towel, and debris under a bed, as well as a Kennedy cup with brown liquid spilled on the floor and splattered on a resident's bed sheet. Additional items such as used tissues, napkins, and a face mask were found under a nightstand. Residents reported that housekeeping did not clean their rooms daily, and sometimes the floors were so dirty it was embarrassing. Unsafe placement of equipment was also noted, with a tabletop fan positioned on a transfer board atop wheelchair handles, and two positioning wedges in direct contact with the floor. Interviews with the Nursing Home Administrator and DON confirmed that the environment should be maintained in good repair and kept clean and homelike, but these standards were not met in the observed areas.
Failure to Provide Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in multiple incidents where residents did not receive timely, person-centered care and supervision. On a specific shift, three residents experienced falls within one hour, including a resident with a history of stroke and dementia who attempted to transfer herself and fell, a resident with severe cognitive impairment who fell over equipment and sustained lacerations requiring hospital treatment, and another resident with dementia and a history of elopement who fell in a shower room while on a 15-minute observation schedule. Staffing records for that shift showed that the number of nurse aides and LPNs scheduled was insufficient for the resident census and acuity, with some staff required to provide one-to-one supervision, further reducing available personnel for other residents. Additional documentation and interviews revealed that residents who were totally dependent on staff for activities of daily living, such as toileting, bed mobility, and transfers, experienced significant delays in care. One resident reported waiting over an hour for call bell response, resulting in incontinence and soiled bedding, particularly during the second and third shifts. Another resident, who enjoyed participating in facility activities, stated he was unable to attend due to a lack of staff to assist him out of bed, and also reported missed showers. Review of shower logs confirmed that most scheduled showers were not provided, and there was no documentation that residents declined or preferred alternative care. Staff interviews and review of staffing schedules confirmed that the facility did not meet minimum nurse aide and LPN staffing ratios on multiple dates, nor did it consistently provide the required 3.2 hours of general nursing care per resident per day as mandated by state regulations. The facility's own policies required additional staff for residents on one-to-one supervision, but records showed that this was not consistently implemented, and staff were expected to provide both one-to-one monitoring and care for the rest of the unit. These deficiencies were confirmed by the Director of Nursing and Nursing Home Administrator, who were unable to provide evidence that staffing levels met regulatory requirements.
Failure to Prevent Elopement and Ensure Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement safety interventions to prevent elopement for a resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors. The resident, who had diagnoses including vascular dementia and required assistance with activities of daily living, was identified as being at risk for elopement and had a care plan in place that included the use of a wander guard bracelet and regular checks. Despite these interventions, the resident was able to exit the building unsupervised and was later found outside by a staff member. Multiple door alarms were activated during the evening of the incident, but staff responses were inconsistent and ineffective. Staff were unable to interpret alarm panels due to the lack of posted zone identifiers, and alarms were repeatedly silenced without confirming the safety of all residents. No immediate headcount or licensed nurse assessment was completed, and the facility's Code Green procedure was not initiated. Communication among staff was poor, with conflicting accounts of the event and a lack of clarity regarding which resident was missing and which door had been used for the exit. The incident was not reported to administration or investigated until approximately 30 hours after it occurred. During this time, no new interventions were implemented to ensure the safety of other residents at risk for elopement. The facility's failure to respond effectively to multiple alarms, identify the missing resident in a timely manner, and follow established elopement protocols resulted in a breakdown of supervision and safety systems for residents identified as being at risk for elopement.
Removal Plan
- Complete a skin assessment on the resident.
- Ensure the resident's wander-guard bracelet is intact and functional.
- Initiate fifteen-minute safety checks.
- Update the resident's care plan to reflect current interventions.
- Review and revise the facility's elopement policy and door alarm protocol.
- Educate all staff on elopement prevention, wandering, resident safety, and identification of alarm zones.
- Check all wander-guard door boxes and door alarms for proper functioning.
- Check all residents with wander-guard bracelets for proper device placement and functionality.
- Complete audits to ensure no other residents are affected by alarm or supervision concerns.
- Complete new elopement risk assessments for all residents.
- Review and update elopement binders and resident care plans.
- Initiate door checks on each shift to be completed by the Maintenance Director or designee.
- Conduct elopement drills by the Maintenance Director or designee.
- Review results of education, audits, and drills at the next QAPI meeting for continued monitoring.
Failure to Prevent Resident Elopement Due to Ineffective Administrative Oversight
Penalty
Summary
The facility administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents. Specifically, the facility did not implement adequate measures to prevent a resident identified as being at risk for wandering from exiting the building unattended and entering an unsafe environment. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) indicated their responsibilities included maintaining safety, staffing, and overall operations in accordance with regulations. However, on the date of the incident, a resident exited the facility without staff supervision, demonstrating that facility systems and oversight were not effective in preventing unsupervised exits for residents at risk of wandering. Interviews with staff, residents, the NHA, and the DON confirmed that established safety measures were not followed, and both equipment and staff procedures failed. Staff expressed uncertainty about their roles in monitoring exit doors and about communication protocols when a resident was missing. This lack of coordination and communication delayed the identification of the incident and assessment of other residents at risk for wandering or elopement. The NHA and DON did not fulfill their essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety, resulting in immediate jeopardy to residents' health and safety.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect three severely cognitively impaired residents from repeated physical abuse by another resident with a known history of aggressive and violent behaviors. The resident responsible for the abuse had diagnoses including Huntington's disease and demonstrated ongoing physical and verbal aggression, wandering, and impulsive behaviors since admission. Despite these documented behaviors, the facility's interventions and supervision were inconsistent and insufficient to prevent further incidents. Multiple incidents occurred in which the aggressive resident physically assaulted other residents, including hitting, hair-pulling, and pushing. These incidents were witnessed by staff and documented in clinical and investigative records. After each event, interventions such as 15-minute checks and 1:1 supervision were ordered; however, there was no evidence that these interventions were consistently implemented. Documentation revealed significant gaps in monitoring records, and staff failed to maintain required supervision, even after repeated episodes of abuse. The facility's failure to implement and maintain adequate supervision and monitoring measures directly resulted in repeated physical abuse of vulnerable residents. The lack of consistent follow-through on ordered interventions, as well as the absence of proper documentation and staff adherence to supervision protocols, allowed the aggressive resident to continue perpetrating abuse against other residents. Facility leadership confirmed these failures during interviews, acknowledging that the measures in place were not sufficient to prevent the abuse.
Failure to Ensure Resident Access to Call Bells and Display Boards
Penalty
Summary
Surveyors observed that multiple residents were unable to access their call bells while in their rooms. Specifically, four residents were found in their beds or wheelchairs with their call bells on the floor, behind the head of the bed, and out of reach. One resident reported that the call bell was frequently inaccessible, requiring alternative means to summon staff assistance. These observations were confirmed by a nurse aide, who acknowledged that the affected residents did not have access to their call bells at the time of the survey. Additionally, two residents reported during a group interview that the display boards for activity calendars in their rooms were installed too high for them to access or read while seated in their wheelchairs. Observations confirmed that the boards were positioned at or above standing eye level, making them inaccessible to the residents. The Nursing Home Administrator acknowledged the facility's responsibility to make reasonable accommodations for residents' needs and confirmed the issue with the display boards.
Failure to Provide Consistent ADL Assistance and Nutrition Support
Penalty
Summary
The facility failed to provide consistent assistance with activities of daily living (ADLs) for two residents who were dependent on staff support. One resident, admitted with a history of cerebral infarction and type 2 diabetes with neuropathy, required moderate staff assistance for showering and was cognitively intact. Despite a physician's order for scheduled showers twice weekly, documentation showed the resident missed several scheduled showers and received bed baths instead, without any record of refusal or preference for bed baths. The facility did not provide evidence that showers were given as planned. Another resident, admitted with diffuse large B-cell lymphoma and dysphagia, was severely cognitively impaired and required supervision for eating. Observations revealed that after staff set up the resident's lunch tray, they left the resident unattended for 25 minutes, during which the resident did not attempt to eat and instead placed a blanket in his mouth. The care plan did not accurately reflect the resident's current functional ability or the level of staff assistance required for eating and other ADLs. Occupational therapy documented a significant decline in the resident's self-feeding ability, indicating total dependence, but this information was not communicated or updated in the care plan, physician orders, or CNA huddle binder. Interviews with facility staff confirmed that the necessary information regarding the resident's decline and required assistance was not effectively communicated to the interdisciplinary team or primary caregivers. As a result, staff were not aware of the resident's need for total assistance with feeding, and the facility failed to provide the necessary services to maintain good nutrition and personal hygiene for the residents involved.
Failure to Ensure Activities Program Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional as required. After the resignation of the previous full-time qualified activities director, a qualified activities director from a sister facility provided temporary coverage until early December. Following this period, the facility appointed a new activities director whose employment was contingent upon obtaining the necessary certification, but this individual had not yet begun the required training program. Oversight was provided remotely by a qualified vice president of life enrichment, but this oversight was limited in scope. The remote oversight did not include directing or delegating the completion of the activities component of the comprehensive assessment, nor did it involve contributing to or directing the contribution to individualized care plan goals and approaches for residents. As a result, the facility did not have a qualified professional actively directing the development, implementation, supervision, and ongoing evaluation of the activities program, as required by regulation.
Failure to Provide Person-Centered Diabetes Management and Physician Notification
Penalty
Summary
The facility failed to provide person-centered care and adhere to professional standards of practice in the management of diabetes for one resident. The resident, who was cognitively intact and had diagnoses including diabetes and end-stage renal disease on dialysis, did not have routine blood glucose monitoring ordered or documented for an extended period despite being prescribed diabetes medications. A consultant pharmacist recommended routine blood glucose monitoring, which was subsequently ordered for a two-week period. During this monitoring, several blood glucose readings exceeded the physician's notification threshold, but nursing staff failed to notify the physician as required, except for one instance. There was also no documentation of ongoing consultation with the physician regarding the resident's diabetes management needs. Additionally, the resident's care plan identified a risk for unstable blood sugars and directed staff to evaluate, record, and report effectiveness of interventions, but there was no evidence of a person-centered care plan addressing adequate diabetes management. The resident expressed a desire for more frequent blood glucose monitoring and was unable to recall the last time this was performed. The last documented blood glucose check was several months prior to the survey, and subsequent laboratory results showed elevated hemoglobin A1C levels. The Director of Nursing confirmed the lack of physician notification for elevated blood sugars and the absence of a person-centered care plan for diabetes management.
Failure to Provide Comprehensive Pain Assessment and Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with systemic lupus erythematosus and poly-osteoarthritis, both conditions associated with acute and chronic pain. The resident's care plan included interventions such as education on pain management, use of non-pharmacological and pharmacological interventions, and monitoring the effectiveness of pain medications. Physician orders were in place for acetaminophen for mild pain and oxycodone for more severe pain, with instructions for administration as needed. On a specific day, the resident reported increasing lower back pain, was tearful, and had a low-grade fever. Nursing documentation indicated that acetaminophen was administered for fever, and the physician was notified. However, there was no documentation of a comprehensive pain assessment at that time, nor was there a numerical pain scale rating or detailed characterization of the pain. Despite multiple complaints of pain and administration of both acetaminophen and several doses of oxycodone, the clinical record did not reflect pain assessments prior to or after medication administration, nor did it document the effectiveness of the interventions provided. Interviews with the resident confirmed ongoing and severe pain that was not adequately assessed or managed by staff, and the Nursing Home Administrator acknowledged the lack of comprehensive pain assessment and documentation. The facility's failure to assess, monitor, and document pain management interventions was not consistent with professional standards of practice or the facility's own pain management policy.
Failure to Implement Smoking Safety Procedures and Timely Assessments
Penalty
Summary
The facility failed to implement and follow its own procedures for smoking safety, as evidenced by the lack of timely smoking safety assessments and incomplete care planning for three residents who smoke. According to the facility's Resident Smoking Policy, residents who choose to smoke must be assessed for smoking safety awareness upon admission, readmission, quarterly, and with any significant change in condition. However, clinical record reviews showed that these assessments were not completed within the required 90-day intervals for all three residents sampled. Specifically, one resident went 138 days without reassessment, another 158 days, and the third 100 days, all exceeding the policy's quarterly requirement. Additionally, the care plan for one resident who was identified as a smoker did not include any interventions or address safe smoking practices, despite the resident's status and the facility's policy. The Director of Nursing confirmed these lapses, acknowledging that the facility did not ensure residents were assessed and monitored for smoking safety as required. These findings were based on clinical record reviews, policy review, and staff interviews.
Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, a review of clinical records and the MDS assessment for Resident 106 revealed a discrepancy in the documented discharge status. The MDS assessment indicated that the resident was discharged to a short-term general hospital, while a progress note on the same date documented that the resident was actually discharged to another long-term care nursing facility. This inaccuracy was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the discharge return-not-anticipated MDS assessment did not accurately reflect the resident's actual discharge location.
Failure to Update Care Plan for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect their current needs and required services. Specifically, a resident admitted with diagnoses including bipolar disorder and diabetes had a psychiatric consult that recommended monitoring and documentation of various behavioral and mood symptoms. However, the resident's comprehensive care plan, last revised after the psychiatric consult, did not include any assessment, goals, or interventions related to bipolar disorder or the monitoring of behavioral symptoms as recommended. A review of the facility's policy confirmed that care plans are required to address all identified medical, nursing, mental, and psychosocial needs. During an interview, the DON acknowledged that the care plan had not been updated to reflect the resident's current mental health status, associated risks, or necessary interventions. This deficiency was identified through clinical record review and staff interview.
Antibiotic Administered Without Documented Clinical Indication
Penalty
Summary
A resident with multiple chronic conditions, including multiple sclerosis, COPD, and dementia, was assessed by nursing staff after exhibiting labored breathing, lethargy, increased respiratory rate, diaphoresis, and other abnormal vital signs. The nurse notified the certified registered nurse practitioner (CRNP), who ordered a one-time dose of Ceftriaxone, a broad-spectrum antibiotic, to be administered intramuscularly, along with laboratory tests and a chest x-ray. The resident received the antibiotic prior to the availability of laboratory or imaging results. The clinical record did not contain any documentation from the physician or CRNP providing a diagnosis or clinical indication for the initiation of the antibiotic therapy. There was no documented clinical rationale for starting the antibiotic before receiving the results of the ordered tests. The Director of Nursing confirmed that no such documentation existed in the resident's record, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Delayed Physician Notification of Abnormal Lab Results
Penalty
Summary
Nursing staff failed to promptly notify the physician of abnormal laboratory results for one resident with significant medical conditions, including diabetes and a malignant brain neoplasm, who was also immunocompromised due to chemotherapy. The facility's policy required nursing to recognize changes in condition and notify the physician as soon as such changes, including abnormal lab results, were identified. Despite this, a urine culture showing greater than 100,000 colonies per milliliter of Enterococcus faecalis was not communicated to the physician until two days after the result was available, and only after surveyor inquiry. There was no documentation to support earlier notification. Additionally, the facility was unable to provide documentation that a urinalysis or culture and sensitivity test had been completed for the resident during a specified month, despite active physician orders for these tests. Staff interviews confirmed that abnormal lab results should be communicated to the physician on the same day they are received, and acknowledged that this did not occur in this instance. The deficiency was cited under 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Provide Timely Dental Services Following Dental Recommendations
Penalty
Summary
The facility failed to provide timely and necessary dental services for a resident who was a Medicaid recipient. The resident, who had a history of cerebral infarction and type 2 diabetes with diabetic neuropathy, was cognitively intact according to a recent MDS assessment. Documentation showed that the resident was seen by a dentist and received a treatment plan recommending impressions for full upper and lower dentures and extractions of several teeth. The treatment plan emphasized the need for prompt action to prevent possible complications, including the risk of infection spreading if the extractions were not performed. Despite these recommendations, the resident reported that the facility had not scheduled the necessary dental appointment for extractions, as advised by the dentist. During interviews, the resident expressed concern about the lack of follow-up, and the Nursing Home Administrator was unable to provide documentation showing that appropriate dental services were arranged or delivered in a timely manner. The administrator could not explain the delay or the lack of action following the dental recommendations.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved two residents, one with moderate cognitive impairment and a history of aggressive behavior, and the other with severe cognitive impairment and a tendency to become fixated on male residents. The facility's policy prohibits any form of abuse, including sexual abuse, but the incident occurred when the two residents were observed kissing, with one resident's hand inappropriately placed on the other's body. The facility did not assess the cognitive capacity of either resident to consent to a sexual relationship, which is a critical step in ensuring the safety and well-being of residents. The lack of assessment meant that the facility could not determine whether the interaction was consensual or if it constituted abuse. The incident was witnessed by staff members, who provided statements confirming the inappropriate contact. The Director of Nursing and the Nursing Home Administrator acknowledged that there was no evidence of capacity assessments for the residents involved. This oversight led to a situation where a resident was not protected from potential sexual abuse, resulting in a deficiency being cited as past non-compliance.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to provide enteral feedings as ordered for a resident, leading to significant unplanned weight loss. Resident 83, who was admitted with diagnoses including intracranial injury and cognitive communication deficit, was dependent on staff for feeding and required a feeding tube. A physician's order was in place for the resident to receive Isosource 1.5 enteral feeding via PEG tube if less than 50% of meals were consumed. However, documentation revealed multiple instances in December 2023 and January 2024 where the resident consumed less than 50% of meals, yet the required bolus enteral feedings were not administered as documented in the Medication Administration Record (MAR). The resident's weight decreased significantly from 154.8 lbs on December 4, 2023, to 112.0 lbs on December 28, 2023, indicating a 27.6% weight loss in 24 days. Despite this significant weight loss, there was no documented evidence that the resident's nutritional status was assessed by the registered dietitian until January 3, 2024, six days after the weight loss was noted. The facility's failure to consistently provide the ordered nutritional support resulted in the resident's progressive weight loss. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility's responsibility to ensure the resident received the necessary nutritional support. However, they were unable to provide evidence that the bolus enteral feedings were consistently administered as ordered, nor could they explain the delay in evaluating the resident's significant weight loss. This deficiency highlights a lapse in the facility's adherence to physician orders and timely nutritional assessment, contributing to the resident's adverse health outcome.
Failure to Address Resident Snack Variety Concerns
Penalty
Summary
The facility failed to adequately address and resolve resident complaints and grievances regarding the variety of snacks offered, as expressed during resident group meetings. The deficiency was identified through a review of Food Committee Minutes and interviews with residents and staff. Residents consistently raised concerns about the lack of variety in snacks, specifically the absence of fresh fruit and limited options for evening snacks. Despite these concerns being voiced in meetings held in March and April 2024, the facility did not take sufficient action to address the issues, as evidenced by continued resident dissatisfaction during a group interview in May 2024. Three residents, identified as Residents 32, 62, and 69, expressed ongoing dissatisfaction with the snack options, noting that their preferences for more variety, including fresh fruit, had not been addressed. Additionally, Resident 54 confirmed the lack of variety in bedtime snacks, which primarily consisted of the same flavor of cookies and ice cream. The facility was unable to provide documentation showing that they had followed up with residents to determine if their concerns had been resolved, indicating a failure to effectively manage and respond to resident grievances.
Inaccurate MDS Assessments for Residents Requiring PASRR
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of two residents. For Resident 7, the annual MDS Assessment dated October 1, 2023, incorrectly indicated that the resident did not require a Level II Preadmission Screening and Resident Review (PASRR) process. However, a Level I PASRR completed on March 7, 2018, and a letter of determination dated April 11, 2018, confirmed that the resident met the criteria for a Level II PASRR and required specialized services. This discrepancy was confirmed during an interview with the Social Services Director. Similarly, Resident 13's annual MDS Assessment dated February 6, 2024, inaccurately reflected that the resident did not require a Level II PASRR process. A review of the clinical record revealed a Level II PASRR letter of determination dated August 5, 2016, indicating the resident met the criteria for specialized services related to a mental health condition. This inaccuracy was also confirmed by the Social Services Director during an interview. These findings highlight the facility's failure to maintain accurate assessments for residents requiring specialized services.
Failure to Follow Bowel Protocols for Two Residents
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for bowel protocols for two residents. Resident 89, who was admitted with diagnoses including diabetes, adult failure to thrive, cerebral infarction, and chronic kidney disease, had physician orders for a bowel regimen that were not followed. Despite having orders for Milk of Magnesia, Dulcolax suppository, and Fleet Enema, there was no documented evidence that the nursing staff administered these as prescribed. The resident went without a bowel movement for eight days from admission and again for four days later in February, without the prescribed interventions being administered. Similarly, Resident 50, admitted with diagnoses including diabetes, end-stage renal disease, and constipation, had physician orders for a bowel regimen that were not followed. The resident did not have a bowel movement for four days in March, and there was no documented evidence that the nursing staff administered the prescribed MiraLAX and Dulcolax suppository. The Director of Nursing confirmed that the staff failed to consistently carry out the physician orders for both residents, and the physician was not timely notified of the extended periods without bowel activity.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being for two residents. Resident 46, who was admitted with diagnoses including cerebral infarction, major depressive disorder, and dementia, exhibited a range of challenging behaviors such as aggression, inappropriate sexual behavior, and refusal of medication and care. Despite these ongoing issues, the facility did not arrange for additional behavioral health consultations after the resident was discharged from medication management consultation due to consistent medication refusal. Resident 46's care plan included interventions for managing his behaviors, but the facility did not provide evidence of assessing the resident as a danger to himself or others following his discharge from behavioral medication management. The resident continued to display aggressive and inappropriate behaviors, including physical aggression towards staff and other residents, inappropriate defecation, and refusal of care. The facility's failure to provide necessary therapeutic social services and behavioral health consultations contributed to the ongoing behavioral issues. Resident 54, diagnosed with depression and PTSD, expressed a desire for therapy or someone to talk to about her feelings. Despite this, there was no documented evidence of supportive social service interventions being implemented to address her depression and medical issues. The facility's lack of action in providing medically-related social services to meet the mental and psychosocial needs of Resident 54 was confirmed by the Director of Nursing.
Failure to Adhere to Medication Storage and Use-By Dates
Penalty
Summary
The facility failed to adhere to proper storage and use-by dates for multi-dose medications and herbal supplements, as observed during a survey. On one of the medication carts, an Insulin Aspart flex pen for two residents was found to be opened and dated beyond the manufacturer's recommended use-by date of 28 days. Additionally, in the first-floor medication storage room, a multi-dose bottle of Tuberculin was found opened and dated beyond the manufacturer's recommended use-by date of 30 days. Furthermore, an opened bottle of Saw Palmetto herbal supplement was found with an expiration date of July 2022. These deficiencies were confirmed by staff members, including an LPN and the Director of Nursing, who acknowledged that the medications and supplements were not discarded within the appropriate time frames as per the facility's policy and manufacturer guidelines. The failure to adhere to these guidelines was observed in both the medication cart and the storage room, indicating a lapse in the facility's pharmacy and nursing services.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to implement its established procedures for assessing residents' ability to safely smoke, as outlined in their Resident Smoking Policy. This policy requires a smoking assessment to be completed upon readmission, quarterly, and with any significant change in a resident's condition. During a review, it was found that three residents identified as current smokers did not have their smoking abilities assessed according to the policy. Specifically, Resident 50's last assessment was dated August 3, 2023, Resident 54's was dated August 11, 2022, and Resident 58's was dated October 1, 2023. There was no documented evidence of any subsequent assessments for these residents, indicating a failure to adhere to the policy. The Nursing Home Administrator confirmed during an interview that all current smokers should have had a quarterly smoking assessment to ensure their smoking privileges remain safe and appropriate. The lack of timely assessments for these residents, who have diagnoses including diabetes, depression, and anxiety, demonstrates the facility's failure to follow its own procedures. This deficiency was identified during a survey conducted on May 7, 2024, and is a violation of 28 Pa. Code 209.3 (a)(c) regarding smoking policies.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to accurately complete the PASRR (Preadmission Screening and Resident Review) process for a resident, leading to a deficiency. The PASRR process, established by the Omnibus Budget Reconciliation Act (OBRA) of 1987, aims to identify individuals with mental illness or intellectual disabilities, ensure appropriate placement, and guarantee necessary services. In this case, the resident was initially admitted with diagnoses of depression and anxiety, and their Level I PASRR indicated a negative screen for serious mental illness. However, upon readmission, the resident's Level I PASRR assessment revealed a positive screen for serious mental illness, including bipolar disorder, depression, and anxiety, necessitating a Level II PASRR evaluation. Despite the requirement for a Level II PASRR evaluation due to the positive screen for serious mental illness, the facility did not complete this evaluation for the resident. The resident had been involuntarily admitted for psychiatric care due to threats of self-harm, further underscoring the need for a comprehensive evaluation. An interview with the social services director confirmed the absence of documented evidence of a completed Level II PASRR evaluation, highlighting the facility's failure to adhere to regulatory requirements.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Upon review of the clinical records, it was found that the care plan for this resident did not identify the symptoms or triggers associated with PTSD, nor did it include specific interventions to minimize these triggers and prevent re-traumatization. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility could not demonstrate the provision of culturally competent, trauma-informed care in line with professional standards and the resident's experiences and preferences.
Failure to Provide Accurate Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required advance notice, a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the residents. According to the Centers for Medicare and Medicaid Services Form Instructions, the NOMNC must be delivered at least two calendar days before Medicare-covered services end. However, the facility provided the resident with a notice dated April 24, 2024, indicating that Medicare would not cover services after April 26, 2024. A review of the clinical records revealed that the resident's skilled nursing facility services actually ended on March 26, 2024, not April 26, 2024. This discrepancy was confirmed by the Nursing Home Administrator during an interview, acknowledging that the facility provided inaccurate dates and failed to give the required advance notice.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
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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