Brookline Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Mifflintown, Pennsylvania.
- Location
- 2 Manor Boulevard, Mifflintown, Pennsylvania 17059
- CMS Provider Number
- 395418
- Inspections on file
- 20
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Brookline Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to follow its abuse and neglect reporting policy by not thoroughly investigating or reporting two separate allegations involving residents. One resident reported that a female staff member was rough, made a threatening remark when asked for positioning assistance, and left her fearful of using the call bell; days later, the resident was found with a large right flank/hip hematoma that required diagnostic testing and an ED visit, yet the facility did not investigate the cause to rule out abuse or report it to required agencies. In another case, a resident who was frequently incontinent and dependent for hygiene was reported by a granddaughter to have received no care all day and was later found soaked through sheets and bed pads; the facility did not treat this as a neglect allegation, did not obtain staff statements, and did not report the concern to appropriate authorities.
The facility failed to develop and implement person-centered care plans for residents diagnosed with dementia. A resident admitted in 2018 and diagnosed in 2022, another admitted in 2022, and a third admitted in 2023 all lacked individualized care plans despite assessments indicating the need. These deficiencies were discussed with the facility's administration.
The facility's main kitchen had several deficiencies, including a large hole in the dishwashing area wall, dust build-up on the air handler, and expired items in the first aid kit and pantry. A drink used for colonoscopy preps was improperly stored with commercial cleaner. Additionally, food temperature logs were incomplete for two dates. These issues were identified during a tour with the Dietary Manager and discussed with the Nursing Home Administrator and DON.
The facility did not ensure that three nurse aides received the mandated 12 hours of annual in-service training. This deficiency was confirmed through a review of education records and interviews with the Nursing Home Administrator and DON, who acknowledged the absence of documentation for the required training.
The facility failed to accommodate the needs of two residents by not responding timely to call bell activations. One resident reported delays of up to an hour, and facility records confirmed multiple instances of prolonged response times. The facility's call bell documentation was inadequate, and staff could not explain the delays.
The facility failed to maintain a clean and orderly environment on Unit 3, as observed by marred drywall behind the beds of two residents. These deficiencies were discussed with the Nursing Home Administrator and DON.
The facility failed to provide written notice of the bed hold policy to two residents or their representatives at the time of hospital transfer. This deficiency was confirmed during interviews with the Nursing Home Administrator and the DON.
A facility failed to provide appropriate treatment for a resident frequently incontinent of bladder. Despite being cognitively intact and requiring assistance for toileting, the facility did not assess the resident's incontinence type or develop a toileting program, as confirmed by the Nursing Home Administrator and DON.
A facility failed to store supplemental oxygen equipment properly for a resident with respiratory conditions. The nasal cannula was found in the back storage area of the resident's wheelchair, unprotected from contamination and in contact with footrests. This was confirmed by a registered nurse and reviewed with the Nursing Home Administrator and DON.
A facility failed to fully assess the risk of side rail entrapment for a resident. Although an assessment and consent were completed, the evaluation only covered zone six, omitting zones one, two, three, and four. This deficiency was confirmed in an interview with the Nursing Home Director and DON.
The facility failed to provide required written notifications to residents and/or their responsible parties for hospital transfers, affecting four residents. The notifications lacked essential information such as the reason for transfer, effective date, and appeal rights. These deficiencies were confirmed by the Nursing Home Administrator and DON.
The facility failed to follow its abuse policy and thoroughly investigate two incidents involving a resident. In both cases, the LPN who documented the events was not the witness, and there was no evidence that the actual witnesses were interviewed or that signed statements were obtained. The Administrator and DON acknowledged these findings.
The facility failed to follow physician orders for bowel protocol medication administration for two residents and did not provide adequate care plan details for a resident with a cardiac pacemaker, resulting in inadequate care.
The facility failed to provide the appropriate physician-ordered enteral nutrition for a resident with a feeding tube. Observations and staff interviews revealed that the pump settings allowed 520 ml of liquid nutrition to infuse over eight hours before initiating the water flush, which did not comply with the physician's order for water every six hours. The facility did not provide evidence that the resident received the prescribed 250 ml of water every six hours until after the surveyor's questioning.
The facility failed to maintain clear and consistent documentation of advance directives for two residents. One resident's POLST indicated full treatment, but a physician's order listed DNR. Another resident's POLST indicated DNI, but the physician's order did not reflect this. Both discrepancies were corrected during the survey.
The facility failed to implement fall prevention measures for a resident and did not secure the main entrance, posing potential accident hazards. A resident's chair alarm was incorrectly placed, and the main entrance was left unsecured without staff monitoring.
A facility failed to administer supplemental oxygen as prescribed for a resident. Despite a physician's order for three liters per minute, observations and staff interviews confirmed the resident was receiving only two liters per minute.
A resident exhibited multiple inappropriate behaviors and was prescribed Prozac on October 24, 2023. However, the medication was not added to the resident's regimen until a month later, despite being noted by nursing staff. The DON confirmed these findings.
The facility failed to maintain a medication error rate below five percent. An LPN improperly administered a Tolterodine Tartrate ER capsule by opening it and mixing it with applesauce, and did not ensure a resident rinsed their mouth after using a Trelegy Ellipta inhaler, leading to a medication error rate of 5.56 percent.
The facility failed to ensure safe and sanitary storage and handling of personal food products for a resident. Expired food items and outdated temperature monitoring logs were found in the resident's personal refrigerator, and additional expired items were observed on a subsequent inspection with the DON. The facility did not adhere to its policy on discarding perishable foods and those showing signs of potential foodborne danger.
Failure to Investigate and Report Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Investigation and Reporting policy by not thoroughly investigating and reporting allegations of abuse and neglect for two residents. The policy, last reviewed on November 20, 2025, required that all reports of abuse, neglect, exploitation, misappropriation of property, mistreatment, and injuries of unknown origin be promptly reported to specified local, state, and federal agencies and thoroughly investigated by facility management. Contrary to this policy, the facility did not treat certain resident and family reports as allegations of abuse or neglect and therefore did not initiate required investigations or notifications. For one resident (CR1), a concern/grievance report dated January 8, 2026 documented that the resident reported a female staff member entered her room the previous night, was grumpy, and stated, “you asked for it, now you got it” after the resident requested a wedge behind her back. The resident reported that a pad was placed on her spine, that she could not find the call bell, and that she was scared. A summary by the DON indicated that the DON and social services director met with the resident, who stated someone was being rough with her at night, did not place a wedge under her back, and that she was afraid to use the call bell in case the person returned. The resident could not identify the staff member because her eyes were closed. The DON reviewed staff and obtained written statements from two night-shift nurse aides, and those aides felt the resident was hallucinating. Subsequently, clinical notes documented a purplish area on the resident’s right flank/hip extending below the right abdominal fold, an ultrasound-confirmed hematoma in that area, and an emergency room visit for a large bruise/hematoma to the right abdomen and hip. The facility was unable to provide any information showing that it investigated the cause of the hematoma to rule out abuse. For another resident (CR2), who was assessed on the admission MDS as frequently incontinent of bowel and bladder and dependent on staff for personal and toileting hygiene, nursing documentation on November 10, 2025 recorded that the resident’s granddaughter informed the nurse that no nurse aide staff had been in the room all day to provide care. The documentation indicated that a nurse aide went into the room at approximately 2:10 PM and was refused entry by the granddaughter, and when the aide later returned to provide care, the resident was found soaked from incontinence through the sheets and bed pads. The Nursing Home Administrator stated that the facility did not identify the granddaughter’s report of no care all day as an allegation of neglect, did not obtain statements from staff who provided or attempted to provide care that day to rule out potential neglect, and did not report the allegation to the appropriate agencies. The DON and Administrator also stated that they did not more thoroughly investigate or report the events involving CR1 because they did not feel there was any allegation of abuse.
Failure to Implement Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for residents diagnosed with dementia, as evidenced by the cases of three residents. Resident 18 was admitted on July 13, 2018, and diagnosed with dementia on October 3, 2022. Despite the facility's assessment on February 9, 2025, indicating the need for a care plan, no person-centered care plan was developed for Resident 18's dementia and cognitive loss. Similarly, Resident 55, admitted on May 15, 2022, with a diagnosis of dementia, also lacked a person-centered care plan despite the facility's assessment indicating the necessity for one. Resident 61, admitted on May 27, 2023, with a dementia diagnosis added on May 31, 2023, was also found to be without a person-centered care plan addressing her dementia and cognitive loss. These deficiencies were identified through clinical record reviews and staff interviews, and were discussed with the Nursing Home Administrator and Director of Nursing on March 20, 2025. The facility's failure to implement these care plans is a violation of the specified nursing services and resident care plan regulations.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen. During an initial tour of the kitchen, a large hole was observed in the wall of the dishwashing area, with two wall tiles fallen onto the ground. There was an extensive build-up of dust on the air handler appliance. The wall-mounted first aid kit contained burn spray and eye wash that were expired, and the pantry area held expired hand wipes. Additionally, a bottled drink used for colonoscopy preps was stored alongside commercial sanitizer/cleaner. A review of the food temperature logs for February 2025 revealed missing documentation for dinner food temperatures on two specific dates. These findings were discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training annually, as mandated by regulations. This deficiency was identified during a review of employee education records and staff interviews. Specifically, three nurse aides, referred to as Employees 1, 2, and 3, did not have documented evidence of completing the necessary training hours. The issue was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of documentation for the required training.
Failure to Timely Respond to Call Bells
Penalty
Summary
The facility failed to provide a reasonable accommodation of needs in response to call bell activations for two residents on Unit 2. Resident 57, who has a diagnosis of dementia but was assessed with no cognitive impairment, reported that staff do not respond to call bell activations in a timely manner, sometimes taking an hour or longer. This concern was corroborated by the Room Event Report, which documented multiple instances of call bell activations with elapsed times exceeding 20 minutes, with some instances extending over an hour. Resident 14, who shares a room with Resident 57, was noted to have cognitive decline and was unable to be interviewed due to confusion. The facility's documentation system for call bell activations was found to be inadequate, as it did not provide resident-specific data, only room-specific data. Interviews with the Nursing Home Administrator and Director of Nursing revealed that the facility could not explain the extended response times. Resident 57 also mentioned that he sometimes rings the call bell for Resident 14 due to the latter's confusion.
Inadequate Housekeeping and Maintenance on Unit 3
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on Unit 3, affecting two residents. Observations on March 18, 2025, revealed that the drywall was marred behind the head of the bed and the recliner of Resident 51, as well as behind the head of the bed of Resident 73. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 20, 2025.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital following a change in their medical condition. Resident 11 was transferred on March 17, 2025, and there was no documentation that the facility provided the required written notice regarding the bed hold policy to the resident or their responsible party. Similarly, Resident 70 was transferred on March 5, 2025, and the facility also failed to document that the resident's representative received the written notice of the bed hold policy. These findings were confirmed during interviews with the Nursing Home Administrator and the Director of Nursing on March 21, 2025.
Failure to Develop Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to promote bladder continence for a resident identified as frequently incontinent of bladder. The facility's policy on urinary continence and incontinence assessment and management requires nursing staff and physicians to screen residents for urinary incontinence, document relevant details, and develop a toileting plan if necessary. However, the clinical record of the resident showed no documented evidence that the facility's physician or nursing staff assessed the resident to determine the type of urinary incontinence or developed an individualized toileting program or plan of care. The resident, who was assessed as cognitively intact with a BIMS score of 15, required extensive assistance from two staff members for toileting. Despite this, the facility did not attempt a urinary toileting program, as indicated in the Minimum Data Set Assessment. The Nursing Home Administrator and the Director of Nursing confirmed these findings, indicating a failure to adhere to the facility's policies and procedures for managing urinary incontinence.
Improper Storage of Supplemental Oxygen Equipment
Penalty
Summary
The facility failed to store supplemental oxygen equipment according to professional standards of practice for a resident with significant respiratory conditions. The resident had a medical history that included acute and chronic respiratory failure with hypercapnia, COPD, and pulmonary embolism. The physician's orders required supplemental oxygen at five liters per minute via nasal cannula to maintain a pulse oximeter reading greater than 90 percent. However, observations revealed that the nasal cannula was improperly stored in the back canvas storage area of the resident's wheelchair, alongside two footrests, exposing it to potential contamination. The deficiency was identified during observations on two consecutive days, where the nasal cannula was found unprotected from environmental contamination and contact with the footrests. This improper storage was confirmed by a registered nurse unit manager, who acknowledged that the wheelchair belonged to the resident. The findings were subsequently reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to adhere to proper respiratory care equipment storage protocols.
Incomplete Side Rail Entrapment Assessment
Penalty
Summary
The facility failed to adequately assess the risk of side rail entrapment for Resident 72, who was one of three residents reviewed for accident hazards. An observation of Resident 72's room revealed a left one-quarter side rail on the bed. Although the facility completed a side rail assessment, reviewed potential risks, and obtained consent on February 7, 2025, the entrapment evaluation was incomplete. The facility only assessed zone six, neglecting to evaluate zones one, two, three, and four, which are critical areas for potential entrapment. This oversight was confirmed during an interview with the Nursing Home Director and the Director of Nursing.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and/or their responsible parties regarding hospital transfers, as required by regulations. This deficiency was identified for four out of five residents reviewed. Specifically, Resident 11 was transferred to the hospital on March 17, 2025, due to a change in condition, but there was no documentation of written notification to the resident or their responsible party. The notification should have included the reason for the transfer, the effective date, the location of the transfer, and information about the resident's right to appeal, among other details. Similarly, Resident 39 experienced multiple hospital transfers between December 2024 and January 2025, yet there was no evidence of written notification to the responsible party. Resident 48 was transferred from February 3 to 7, 2025, and Resident 70 from March 5 to 7, 2025, without the required written notifications. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing during interviews conducted on March 21, 2025.
Failure to Investigate Abuse Incidents
Penalty
Summary
The facility failed to initiate their abuse policy and thoroughly investigate incidents to rule out the potential for abuse for Resident 64. The policy entitled Abuse Investigation and Reporting, last reviewed on November 17, 2023, requires that if an incident, suspected incident, or resident abuse is reported, the Administrator will assign the investigation to an appropriate individual. This individual is supposed to review the resident's medical record, interview the person reporting the incident, and interview any witnesses to the incident, obtaining written and signed statements. However, the facility did not follow these procedures for two incidents involving Resident 64. In the first incident, nursing documentation dated January 4, 2024, indicated that Resident 64 rubbed a female resident's buttocks two times and laughed when told to stop. Employee 3, an LPN, documented the event but was not the witness, and there was no evidence that the actual witness was interviewed or that a signed statement was obtained. In the second incident, nursing documentation dated February 23, 2024, indicated that Resident 64 was found holding a female resident's arm and kissing her, and later blocking her from leaving her bathroom. Again, Employee 3 documented the event but was not the witness, and there was no evidence of a thorough investigation. The Administrator and Director of Nursing acknowledged these findings during an interview on March 21, 2024.
Failure to Follow Bowel Protocol and Pacemaker Monitoring
Penalty
Summary
The facility failed to provide the highest practicable care regarding bowel protocol medication administration for two residents and the use of a cardiac pacemaker for another resident. For the first resident, the clinical record revealed a care plan addressing constipation with specific physician orders for Milk of Magnesia, Dulcolax suppository, and Fleet's Enema. Despite documented no bowel movements over several days, there was no indication that staff offered or the resident refused the prescribed PRN medications. Similarly, the second resident had physician orders for bowel management, but staff did not administer the PRN medications despite several days of no bowel movements, nor was there any documentation of refusal by the resident. These findings were confirmed in a meeting with the Nursing Home Administrator and Director of Nursing. For the third resident with a cardiac pacemaker, the clinical record indicated an active physician order for pacemaker checks per the cardiology schedule. However, the plan of care and physician orders lacked details on the type of pacemaker, the method of checks, and emergency procedures for utility outages. The resident had a dual chamber pacemaker for complete heart block, and the pacemaker monitoring machine was found functional in the resident's room. The Director of Nursing confirmed the continuous monitoring but was unaware of the communication method between the monitor and the cardiology office, and this information was not included in the resident's plan of care. The deficiencies highlight the facility's failure to adhere to physician orders and care plans for bowel management and pacemaker monitoring, resulting in inadequate care for the residents. The lack of documentation and follow-through on prescribed interventions and the absence of detailed care plans for critical medical devices were significant issues identified during the survey.
Failure to Adhere to Physician's Orders for Enteral Nutrition
Penalty
Summary
The facility failed to provide the appropriate physician-ordered enteral nutrition for a resident with a feeding tube. The resident had an active physician's order to receive Isosource 1.5 liquid nutrition at a rate of 65 ml per hour and 250 ml of water every six hours. However, observations and staff interviews revealed that the pump settings allowed 520 ml of liquid nutrition to infuse over eight hours before initiating the water flush, which did not comply with the physician's order for water every six hours. This discrepancy was confirmed by a licensed practical nurse who stated that the pump settings were typically cleared and reset at the beginning and end of her shift, approximately every eight hours, not every six hours as required by the physician's order. The clinical record review showed that staff documented providing 520 ml of feeding and 250 ml of water every shift from the beginning of the month until the surveyor's questioning. It was only after the surveyor's intervention that the physician's order was revised to align with the actual practice of infusing 390 ml of feeding and 250 ml of water every six hours. The facility did not provide evidence that the resident received the prescribed 250 ml of water every six hours until after the surveyor's questioning, indicating a failure to adhere to the physician's orders for enteral feeding and hydration.
Failure to Maintain Consistent Advance Directives
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for two residents. For Resident 32, the clinical record showed a POLST form signed by the responsible party indicating a wish for full treatment, including CPR. However, a physician's order dated the next day indicated a DNR status, with no documented evidence of a change in the resident's or responsible party's wishes. This discrepancy was only identified and corrected during the on-site survey. For Resident 26, the clinical record had an active physician's order for full code treatment without specific directions. A POLST signed by the resident's son and initialed by the physician indicated full code treatment but refused intubation (DNI). This DNI omission was identified during the surveyor's review and was corrected following the surveyor's questioning. Both cases highlight the facility's failure to maintain accurate and consistent documentation of residents' advance directives.
Failure to Implement Fall Prevention and Secure Main Entrance
Penalty
Summary
The facility failed to implement interventions to prevent falls and/or injuries for one resident and failed to prevent a potential accident hazard at the facility's main entrance. Specifically, Resident 57 had a physician's order for a sensor pad alarm to be applied to her chair and checked every shift for safety. However, observations on two separate occasions revealed that the alarm was placed on her wheelchair instead of her recliner, where she was seated. Concurrent interviews with Resident 57's family confirmed these observations, indicating a failure to follow the prescribed safety measures for the resident. Additionally, the facility's main entrance was found to be unsecured during the early morning hours, with no staff present to monitor the area. This was observed on a specific date when the front doors were open, and no staff were within visualization of the entrance. The Nursing Home Administrator confirmed that there was no staff assigned to monitor the unsecured front doors, posing a risk that a resident could exit the facility unnoticed. This lack of supervision and security at the main entrance was acknowledged by the facility's administration during the surveyor's questioning.
Failure to Administer Prescribed Supplemental Oxygen
Penalty
Summary
The facility failed to administer supplemental oxygen as prescribed by the physician for a resident. Clinical record review revealed an active physician's order dated January 12, 2023, instructing staff to administer supplemental oxygen via a nasal cannula at three liters per minute. However, observations on March 19, 2024, and March 21, 2024, revealed that the resident was receiving oxygen at a rate of two liters per minute. Interviews with a nurse aide and a licensed practical nurse confirmed the incorrect oxygen administration setting, which did not align with the physician's order.
Failure to Initiate Behavioral Health Treatments
Penalty
Summary
The facility failed to ensure necessary behavioral health treatments were initiated for a resident. The clinical record review revealed that the resident exhibited multiple documented behaviors, including inappropriate sexual behaviors and disruptive actions, from August 9, 2023, until October 24, 2023. A psychiatric evaluation on October 24, 2023, resulted in a new order for the resident to start Prozac 10 mg daily. However, this new order was noted by nursing staff on October 30, 2023, but was not added to the resident's medication regimen until November 23, 2023, a month after it was ordered. The Director of Nursing confirmed these findings during an interview on March 21, 2024.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a medication error rate of 5.56 percent based on 36 medication opportunities with two medication errors. During a medication administration pass, a licensed practical nurse (LPN) opened a Tolterodine Tartrate ER capsule and mixed its contents with applesauce before administering it to the resident, contrary to the physician's order and the medication package instructions, which specified that the capsule should be swallowed whole and not crushed or chewed. Additionally, the same LPN administered a Trelegy Ellipta inhaler to the resident without following the proper post-administration instructions. The resident was supposed to rinse her mouth with water and spit it out after using the inhaler, as per the physician's order and manufacturer's instructions. Instead, the resident took a drink and swallowed the liquid immediately after administration, and did not rinse her mouth as directed. These actions were confirmed through observation, clinical record review, and staff interview.
Failure to Ensure Safe and Sanitary Storage of Personal Food Items
Penalty
Summary
The facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for one of two nursing units. Specifically, in Resident 57's room, a personal refrigerator was found with outdated temperature monitoring logs and expired food items. The temperature monitoring log was last completed in April 2023, and the refrigerator contained items such as an opened bottle of ranch dressing with a use-by date of November 24, 2022, single-serve lemonade cartons with a use-by date of March 15, 2024, and a cheese stick with a use-by date of July 26, 2023. Additionally, the freezer section had ice encasing two single-serve containers of ice cream with unknown use-by dates, and there were undated squares of homemade peanut butter fudge on top of the refrigerator that were dried and hard. These observations were confirmed by Resident 57's family member. Further inspection on a subsequent date with the Director of Nursing (DON) revealed additional expired items, including an open container of butter with a use-by date of September 28, 2023, and a bag of peanuts with a use-by date of July 23, 2023, found on Resident 57's wheelchair. The DON confirmed these observations. The facility's policy on foods brought by family/visitors, last reviewed without changes on November 17, 2023, states that perishable foods should be discarded on or before the use-by date and any food showing signs of potential foodborne danger should be discarded by nursing or food service staff. The facility failed to adhere to this policy, leading to the deficiency noted in the report.
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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