Buffalo Valley Lutheran Villag
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewisburg, Pennsylvania.
- Location
- 189 East Tressler Boulevard, Lewisburg, Pennsylvania 17837
- CMS Provider Number
- 395261
- Inspections on file
- 24
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Buffalo Valley Lutheran Villag during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A review found that nursing staff, including LPNs and RNs, lacked documented competencies for essential care areas such as enteral tube feeding, use of lifts, catheter care, medication administration, transmission-based precautions, IV therapy, and dressing changes, despite caring for residents with these needs.
Surveyors observed that the facility's kitchen and food storage areas were not maintained in a sanitary manner, with greasy build-up on equipment, food debris and unidentified fluids on floors, expired food items in storage, and inadequate protection of clean pans from environmental contamination. These conditions were confirmed during a walkthrough with the dietary manager and reviewed with facility leadership.
The facility did not provide timely written notification to two residents when their Medicare payment coverage changed. In both cases, required notices about the end of Medicare coverage and the transition to private payment were either not delivered within the mandated timeframe or not properly discussed with the responsible party, as confirmed by record review and staff interviews.
A resident's confidential health information was disclosed when a binder containing survey results, including a complaint deficiency letter with the resident's name and identifier, was placed in a publicly accessible area. This action violated facility policy and HIPAA requirements for PHI confidentiality.
The facility did not develop baseline care plans within 48 hours of admission for two residents, one with anticoagulant and insulin needs and another with a Stage 4 pressure ulcer and PICC line. Key interventions and complications related to their conditions were not addressed in the initial care plans, as confirmed by staff and record review.
A resident with dementia and high risk for skin breakdown developed MASD on the sacrum, but staff failed to routinely or comprehensively reassess the wound after the initial evaluation. Documentation repeatedly noted the skin issue as new and not evaluated over several months, with no evidence of ongoing assessment to monitor improvement or worsening.
A resident with a sacral Stage 2 pressure ulcer was not assessed for three weeks, contrary to facility protocol requiring weekly wound evaluations. During this period, the ulcer progressed to Stage 3, and the DON confirmed that required documentation and assessments were not completed.
A resident with declining mobility and new limitations in range of motion did not receive timely or appropriate therapy interventions. Despite documented decline and recommendations for a restorative ambulation program, there was no evidence that such a program was implemented, and therapy services were delayed. Facility leadership confirmed both the delay and lack of documentation for the required restorative program.
A resident experienced a decline from bowel continence to frequent incontinence, but staff did not review observation records or implement individualized interventions to address this change. The care plan required staff assistance with toileting, yet documentation showed a reduction in scheduled toileting times, and facility leadership confirmed there was no policy for bowel continence.
Two residents were involved in incidents where medications were found unsecured in their rooms, including a resident with dementia found taking unidentified pills and another resident's room where tablets were discovered on the floor and improperly disposed of by an LPN. The medications were not properly secured or disposed of according to facility policy, and in one case, the medication was not ordered for the resident.
Multiple black, winged insects and a large spider were observed in the kitchen, with staff confirming the insects had been present for over a week. Pest control records showed no prior notification to pest management about the issue, and only after the survey was a visit documented that identified flies around drains due to grease and food buildup. The facility did not maintain a pest-free kitchen environment.
During an inspection, discarded medical gloves, debris, paper products, and a washcloth were found around two dumpsters outside the kitchen dock entrance. A plastic apple sauce container and other debris were also observed between the lids of one dumpster. These issues were confirmed with the dietary manager, NHA, and DON.
A resident's family submitted a grievance regarding the unauthorized administration of Morphine and an allegation of abuse by an LPN. The facility did not provide the requested written explanation or documentation, failed to investigate or report the abuse allegation, and staff were unaware of the requirement to issue written grievance decisions. The grievance was not considered resolved by the family, and the issue was only revisited after surveyor intervention.
A resident was allegedly subjected to force-feeding and aggressive behavior by family members, as observed and documented by nursing staff. Despite these observations and concerns, the facility did not complete an incident report, obtain witness statements, remove the family from contact with the resident, or notify regulatory agencies, in violation of its abuse prevention policy.
A resident at Buffalo Valley Lutheran Village was improperly restrained with a shawl tied to her wheelchair by a nurse, without a physician's order or care plan. Despite being informed of the inappropriate use, the nurse continued the practice, and supervisory staff failed to suspend the nurse immediately, allowing further potential misuse. The facility lacked evidence of staff education on restraint policies following the incident.
A resident with a history of falls experienced multiple incidents where the VST alarm system failed to alert staff, leading to repeated falls. The facility did not thoroughly investigate these discrepancies or implement new interventions to improve the system's reliability. Despite the presence of a plan of care, the facility's investigations were inadequate, contributing to ongoing fall risks.
The facility failed to follow physician orders for two residents with nutrition and hydration needs. A resident on fluid restriction did not receive all requested beverages, and another resident with significant weight loss did not receive prescribed fortified foods and extra gravy. Staff acknowledged these oversights, indicating a lack of adherence to dietary requirements.
The facility failed to develop and implement individualized care plans for three residents diagnosed with dementia, despite assessments indicating the need for such plans. An interview with the DON confirmed the absence of documentation for these care plans, violating nursing service regulations.
A facility failed to reassess a resident's need for Zyrtec, an allergy medication, despite a consultant pharmacist's recommendation and a physician's agreement to do so. The medication was administered daily for three months without reassessment, as confirmed by the DON.
A facility failed to provide written notice of the bed-hold policy to a resident's responsible party during a hospitalization. The resident's sister, who was the responsible party, only received verbal communication about the hospitalization and did not receive the required written notice. The facility claimed the notice was sent with the resident to the hospital, but there was no evidence to confirm receipt by the responsible party.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS incorrectly stated a discharge to a hospital, while records showed a discharge home. Another resident's MDS inaccurately noted antibiotic use, with no evidence of such treatment. These errors were confirmed by facility staff.
A resident with CHF experienced significant weight gain due to fluid retention, which was not properly monitored or reported by the facility staff as per physician orders. Despite orders for daily and weekly weight assessments, the staff failed to notify the physician of a substantial weight increase, leading to respiratory distress and hospitalization. The deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to provide physician-ordered services to maintain range of motion for two residents. One resident did not receive a prescribed palmar roll for contracture prevention, and there was no documentation of required skin checks. Another resident experienced a decline in lower extremity range of motion without appropriate assessment or intervention. The facility did not ensure these residents received necessary treatments to maintain or improve their range of motion.
The facility failed to obtain informed consent and assess bed rail risks for two residents. One resident had enabler bars despite therapy's assessment deeming them unnecessary, with no documented consent or risk education. Another resident had a side rail without informed consent from a responsible party, and the facility could not verify bed suitability due to incomplete documentation.
The facility did not ensure that all nurse aides completed the required 12 hours of annual in-service education. Two nurse aides failed to meet this requirement, with one completing only 7.25 hours and the other 9.0 hours. The training was to include dementia care and abuse prevention, as confirmed by the NHA and DON.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Lack of Documented Nursing Staff Competencies for Specialized Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff, including both LPNs and RNs, possessed the appropriate competencies and skill sets necessary for the care and assessment of residents with specific clinical needs. Documentation and staff interviews revealed that there was no evidence of competency validation for staff responsible for residents requiring enteral tube feeding, use of lifts, catheter care, medication administration, transmission-based precautions, intravenous therapy, and dressing changes. The review identified that the facility had multiple residents with these care needs, including those receiving medications, using lifts, with indwelling urinary catheters, requiring dressing changes, under enhanced barrier precautions, and receiving IV therapy or enteral tube feedings. Despite these needs, the facility was unable to provide documentation confirming that the involved nursing staff had been assessed for competency in these areas.
Unsanitary Food Storage and Kitchen Conditions Identified
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and did not maintain the kitchen environment in a clean condition. During an observation of the main kitchen with the dietary manager, surveyors found a black, greasy build-up on the splash guard and surrounding hoses near the dishwasher. Cooking pans identified as clean were stored on a rack with significant debris, crumbs, and dirt, and were not protected from the ambient environment. The walk-in cooler floor had food debris and dirt, especially under storage racks, and there were two red-colored puddles of fluid on the floor. A box of chicken breasts with rib meat was stored on a bottom shelf next to a puddle of unidentified fluid. In the walk-in freezer, a package of ravioli and waffles were found with use-by dates that had already passed. Additional unsanitary conditions included two black-colored, wheeled carts with extensive grease and dirt build-up, and a stainless-steel table with a coffee machine that had debris in the shelving area underneath and brown dried stains on the adjacent wall. In a storage area, a shelving rack holding cooking pans on the bottom shelf had an extensive build-up of cobwebs between the pans and the wall, and there was no splash guard to protect these items from mop splash. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Timely Notification of Medicare Coverage Changes
Penalty
Summary
The facility failed to provide timely written notification to residents regarding changes in their Medicare payment coverage, as required by federal regulations. For one resident, services were primarily paid for by Medicare Part A, but the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare coverage. Documentation showed that the resident was scheduled for discharge and no longer required skilled therapy, but the required notice was not provided within the mandated timeframe. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the resident did not leave against medical advice and that the notice was not issued as required. For another resident, Medicare A coverage ended and the resident transitioned to private payment. Although the responsible party signed the NOMNC and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), the facility did not document that staff discussed the change in payment and the estimated cost per day with the responsible party as soon as reasonably possible when the change in coverage was anticipated. The required notification and discussion regarding financial responsibility were not completed in a timely manner, as confirmed by review of the clinical record and interviews with facility leadership.
Resident Health Information Disclosed in Public Area
Penalty
Summary
The facility failed to protect the confidentiality of a resident's personal and medical information by placing a binder labeled 'Department of Health Surveys' in the main lobby, which was accessible to the public. The binder contained the full health survey and complaint survey results, including a complaint deficiency letter and the associated Statement of Deficiencies (Form CMS-2567) for a complaint investigation. The letter specifically identified a resident by name and included their specific resident identifier, thereby disclosing protected health information (PHI) in violation of the facility's confidentiality policy and HIPAA requirements. This lapse was confirmed through policy review, direct observation, and staff interviews.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents. For one resident admitted after hospitalization for left lower extremity cellulitis and a venous stasis ulcer, the clinical record showed that his medication regimen included daily Warfarin, and he was later started on insulin for prediabetes. However, the baseline care plan did not address the use or complications of anticoagulant therapy, nor did it include the use of insulin for elevated blood sugars. The care plan for anticoagulant therapy was not initiated until one week after admission, and there was no evidence that insulin use was included in the care plan during the initial period after admission. Another resident was admitted with a Stage 4 sacral pressure ulcer and a PICC line for intravenous antibiotics due to sacral osteomyelitis. The baseline care plan did not address interventions for the resident's skin integrity impairment or the care and potential complications of the PICC line. A care plan for the pressure ulcer was not initiated until more than two weeks after admission, and no care plan was developed for the PICC line. These omissions were confirmed by staff interviews and clinical record review.
Failure to Routinely Assess and Document Wound Status
Penalty
Summary
Facility staff failed to provide the highest practicable care regarding wound assessment for a resident with dementia and high risk for skin breakdown. The resident was identified as having a Braden Score of 12, indicating high risk for pressure ulcers, and was noted to be incontinent of bowel and bladder. Initial documentation on June 6, 2025, identified the development of moisture-associated skin damage (MASD) on the sacrum, with measurements recorded and a fax sent to the medical provider. The care plan included the use of a moisture barrier and noted the resident's risk for altered skin integrity. Despite the initial assessment, subsequent clinical documentation repeatedly indicated that the skin issue had not been evaluated, and staff continued to document the wound as new over several months. There was no evidence that the MASD was routinely or comprehensively reassessed after the initial evaluation to determine if the wound was improving or worsening. An interview with the Director of Nursing confirmed that no further evidence of ongoing assessment could be provided.
Failure to Assess and Monitor Pressure Ulcer Progression
Penalty
Summary
The facility failed to assess and implement appropriate treatment and services to promote the healing of a pressure ulcer for one resident. According to the facility's Pressure Injury Treatment Protocol, all pressure injuries are to be assessed weekly and as needed, with specific actions required if the wound does not improve within 14 days. Clinical records show that a resident was admitted with a Stage 2 sacral pressure ulcer, which was initially measured and assessed by a wound care specialist on two occasions within the first nine days of admission. However, after April 24, there was a gap of three weeks without any documented assessment of the wound. During this period without assessment, the resident's pressure ulcer progressed from Stage 2 to Stage 3, indicating a deterioration in the wound. The Director of Nursing confirmed that the pressure ulcer was not assessed at least weekly as required, and that documentation of the wound's date observed, location, staging, and size was missing for the three-week period. This failure to follow the facility's protocol resulted in a lack of timely evaluation and intervention for the resident's pressure ulcer.
Failure to Provide Appropriate ROM and Mobility Services
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve range of motion. The resident, who was previously able to walk 150 feet with supervision or minimal assistance and had no documented limitations, began experiencing an unsteady gait, shuffling, and difficulty lifting his right foot. Despite a request from the resident's wife for a physical therapy screen due to these mobility concerns, the initial therapy referral indicated no skilled therapy needs and no change in function. Subsequent assessments documented a decline in the resident's ability to perform activities of daily living, including increased assistance required for ambulation, toileting hygiene, and dressing. A therapy referral was eventually made for the resident's significant decline, and occupational therapy evaluated the resident, noting no further needs but referring to physical therapy for ambulation training. Physical therapy did not assess the resident until over a month later, after which a restorative ambulation program was recommended. However, the facility was unable to provide any documentation that such a restorative nursing program was implemented for the resident, despite physical therapy's recommendation and the resident's ongoing decline. Interviews with facility leadership confirmed both the delay in therapy services and the absence of evidence for the restorative program.
Failure to Assess and Implement Individualized Bowel Continence Interventions
Penalty
Summary
The facility failed to assess and implement individualized interventions to promote bowel continence for a resident whose continence status declined over time. Clinical record review showed that the resident was initially assessed as continent of bowel, but subsequent Minimum Data Set (MDS) assessments documented a decline to occasional and then frequent bowel incontinence. Despite this change, there was no evidence that staff reviewed the resident's bowel and bladder observation records to develop or implement specific interventions tailored to the resident's needs. Additionally, the resident's care plan indicated a need for staff assistance with toileting, but documentation revealed inconsistencies in the frequency of toileting assistance offered. Initially, staff were to assist the resident at multiple times throughout the day, but later documentation showed a reduction in these scheduled toileting times. Interviews with facility leadership confirmed the absence of a policy addressing bowel continence, and the findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Ensure Medication Security and Proper Disposal
Penalty
Summary
The facility failed to ensure proper medication security for two residents. In one instance, a resident with dementia and cognitive deficits was found in her room taking two unidentified pills, with no documentation indicating where the medication originated or how many pills had been ingested. The nurse on duty was unaware of the source or type of medication, and there was no record of the resident's morning medications being administered. The incident was not documented at the time it occurred, and the medications were removed and disposed of by a unit LPN without clear adherence to established procedures. In another case, a privately paid caregiver discovered a medication tablet on the floor of a resident's room and reported it to the unit nurse, who disposed of it in the room's garbage receptacle. Further observation revealed another tablet on the floor near the trash, which was identified as Omeprazole 20 mg, a medication not ordered for the resident. These events demonstrate lapses in medication storage and security, as medications were found unattended and accessible in resident areas, and disposal did not follow the facility's outlined protocols.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the main kitchen area, as evidenced by direct observation and staff interview. During an inspection of the kitchen, multiple black, winged insects were observed on the wall of the dishwashing area, and additional insects were seen on the ceiling near a vent, which also had unidentified splash stains. A large spider was also observed moving across the floor and entering a floor drain. The dietary manager confirmed that the insects had been present for at least one and a half weeks, and that traps had been placed in an attempt to address the issue. Review of pest control documentation showed that while the facility had received general pest control and exterior treatments in previous months, there was no evidence that the pest control service had been notified about the presence of winged insects in the kitchen. Only after the survey was a pest management visit documented, which identified phorid flies and fruit flies around the drains due to grease and food buildup. The facility did not maintain a pest-free environment in the main kitchen, as required by regulations.
Improper Containment and Disposal of Garbage at Facility Dumpsters
Penalty
Summary
The facility failed to properly contain and dispose of garbage at both observed dumpsters located outside the kitchen dock entrance. During an observation with the dietary manager, discarded medical gloves, debris, paper products, and a washcloth were found around the dumpsters. Additionally, a discarded plastic apple sauce container and unidentified debris were observed between the lids on top of one dumpster. These findings were confirmed during a meeting with the Nursing Home Administrator and Director of Nursing.
Failure to Promptly Resolve and Communicate Grievance Decision
Penalty
Summary
The facility failed to promptly resolve a grievance submitted by the family of a resident who was determined to lack capacity to understand her rights and responsibilities. The grievance, submitted by the resident's son and daughter, alleged unauthorized administration of a narcotic pain medication (Morphine) and included an accusation by a staff member that the family was abusing the resident by force-feeding and withholding pain medication. The family requested a detailed written explanation of the events, including vital signs, medication administration records, and hospital discharge documents. Although the facility's grievance policy required prompt investigation and communication of resolution, it did not specify the right to a written decision, and the family did not receive the requested written documentation or a thorough investigation into their concerns. Interviews with the family confirmed that they did not consider the grievance resolved, as they had not received the information they requested or a written response. The Grievance Officer and clinical manager were unaware of the regulatory requirement to provide written grievance decisions, and the facility did not investigate or report the abuse allegation to the appropriate authorities. The grievance was only reopened after the surveyor's inquiry, indicating that the facility did not follow its own policy or regulatory requirements regarding grievance resolution and communication.
Failure to Investigate and Report Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an incident of potential resident abuse involving a resident and her family members. Nursing documentation indicated that a family member was observed force-feeding the resident, aggressively forcing her head forward, shaking her shoulder, and yelling at her, despite the resident expressing discomfort and refusing food. Staff documented concerns about mistreatment and reported the situation to a supervisor, but no incident report was completed, and no witness statements were obtained from those present during the incident. The facility did not remove the family members from contact with the resident to ensure her safety during the investigation, as required by policy. Additionally, the facility did not notify the appropriate regulatory agencies, such as the Department of Health or Area Agency on Aging, about the alleged abuse. The facility's abuse prevention policy referenced state-specific guidelines for Illinois and Missouri but did not include Pennsylvania's regulatory requirements. Interviews with staff and family confirmed the incident and the lack of a formal investigation or reporting. The Director of Nursing acknowledged that no incident report was filed and that the required steps to protect the resident and investigate the allegation were not taken.
Improper Use of Physical Restraints
Penalty
Summary
Buffalo Valley Lutheran Village was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to ensure that a physical restraint was used for the treatment of medical symptoms for one resident. The incident involved a nurse who tied a resident to her wheelchair with a shawl, despite the absence of a physician's order or a plan of care authorizing such a restraint. The resident had a history of noncompliance with transfer status and behaviors of frequently placing herself on the floor. The facility's policies on abuse prevention and restraint use were not adhered to, as evidenced by the actions of Employee 1, who tied the resident to her wheelchair multiple times. Despite being informed by other staff members that the use of the shawl as a restraint was inappropriate, Employee 1 continued to use it. The supervisory staff, including Employee 2, failed to immediately suspend Employee 1 after the initial report of inappropriate restraint use, allowing the nurse to continue working and potentially restrain other residents. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that there was no evidence of counseling for Employee 2 regarding the failure to suspend Employee 1. Additionally, there was no evidence of staff education following the incident to reinforce the facility's policies on restraint use and resident protection during abuse investigations. This lack of immediate action and education contributed to the facility's non-compliance with the regulations.
Plan Of Correction
Please accept the following Plan of Correction as the facility's credible allegation of compliance with F604. This Plan of Correction is being submitted in response to the regulatory requirement and should not be considered an admission of guilt or liability by the facility. Resident #1 assessed by RN supervisor on 2/12/2025 after removal of shawl. No injuries or change in demeanor/level of alertness noted. Employee 1 was suspended pending investigation on 2/11/2025 and was terminated from employment on 2/13/2025. Residents residing in the facility have the potential to be affected. Resident #1 and all residents will be free from restraints. All residents residing in facility on 2/28/2025 will be audited for restraints. Facility staff educated on policy and procedure that residents should be free from restraints. Education included: - Reporting of improper use of restraint - Proper consent, order, and managing of restraint if a restraint is needed - RN supervisors/managers were re-educated on steps to take when abuse is witnessed or reported to them. - New Hire orientation education reviewed and revised to include education that residents will be free from restraint. The Director of Nursing or designee will audit 20 random residents weekly x 4 weeks, then 10 residents monthly x 2 months for improper restraint use. Results will be reported to the Executive Director. Any variance noted will be corrected immediately. The Executive Director or designee will report results of the audits monthly in the Quality Improvement meeting. Trends and analysis will be evaluated. If there are any negative trends or analysis the community will adjust the plan to assure that residents remain free from restraints.
Failure to Investigate and Address Fall Prevention System Deficiencies
Penalty
Summary
The facility failed to thoroughly investigate and implement individualized interventions to prevent falls for a resident identified as having fall concerns. The resident, who had a history of falls, experienced multiple incidents where the fall prevention system, VST, did not function as intended. Despite the presence of a plan of care that included the use of VST and other alarms, the facility did not adequately ensure the reliability of these systems, leading to repeated falls. The resident's clinical records revealed numerous falls over a period of ten weeks, with several incidents where the VST alarm failed to alert staff. Interviews and documentation indicated that the facility did not investigate the discrepancies in the alarm system's functioning or provide evidence of new interventions to improve its reliability. The facility's interdisciplinary team often noted that the plan of care was followed, despite evidence suggesting that the VST system was not functioning properly. The facility's investigations into the falls were inadequate, as they did not determine the duration of the VST alerts or whether staff received them. Additionally, there was no evidence that skilled therapy evaluated the resident after certain falls, and the facility did not report the failure of the plan of care intervention in the required notifications. The lack of thorough investigation and failure to address the alarm system's deficiencies contributed to the ongoing risk of falls for the resident.
Failure to Implement Nutrition and Hydration Interventions
Penalty
Summary
The facility failed to implement interventions consistent with physician orders and resident preferences for two residents with nutrition and hydration concerns. Resident 43, who was on a physician-ordered fluid restriction of 1800 ml per day, did not receive the milk he requested during a lunch meal, despite it being listed on his meal tray ticket. The nurse aide confirmed the oversight, acknowledging that Resident 43 should have received his requested beverages, including milk. Resident 66 experienced a significant weight loss of 9.88% over one month. Despite physician orders for extra gravy with meat and fortified food during lunch, these interventions were not consistently provided. During a lunch meal observation, Resident 66 did not receive the extra gravy or fortified mashed potatoes as indicated on her meal ticket. The dietary aide admitted to not providing these items, revealing a lack of understanding of the fortified diet requirements. These deficiencies were reviewed with the Nursing Home Administrator and the Director of Nursing.
Failure to Implement Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for three residents diagnosed with dementia. Resident 52 was admitted on February 24, 2021, and diagnosed with dementia on November 8, 2022. Despite the facility's assessment on July 3, 2024, indicating the need for a care plan, no such plan was developed or implemented. Similarly, Resident 60, admitted on August 12, 2021, was diagnosed with dementia with agitation on May 30, 2023. The facility's assessment confirmed the need for a care plan, but none was created or executed. Resident 79, admitted on December 11, 2023, with a diagnosis of dementia with anxiety, also lacked a person-centered care plan despite the facility's assessment indicating its necessity. An interview with the Director of Nursing on September 29, 2024, confirmed the absence of documentation for individualized care plans for these residents. This deficiency is a violation of 28 Pa Code 211.12 (d)(1)(3)(5) regarding nursing services.
Failure to Reassess Unnecessary Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medication. A clinical record review for a resident revealed a physician order for Zyrtec, an allergy medication, to be administered daily for a cold and runny nose. A consultant pharmacist recommended that the physician reassess the need for the continued use of Zyrtec, which the physician agreed to do in two weeks. However, there was no evidence in the clinical record that staff reassessed the resident's need for Zyrtec after the two-week period. The medication order remained active and was administered daily until it was discontinued several months later. An interview with the Director of Nursing confirmed that the staff did not complete the reassessment of the resident's use of Zyrtec, resulting in the medication being administered for three months beyond the recommended reassessment period.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice to a resident's responsible party regarding the duration of the bed-hold policy during a hospitalization. This deficiency was identified during a clinical record review and interviews with staff and family members. Specifically, the sister of the resident, who is the responsible party, reported that all communication from the facility about the hospitalization was verbal, and she did not receive any written notices. The resident had been sent to the hospital after being found on the floor with swelling on her forehead, and the responsible party had verbally requested a bed hold. The facility claimed that a copy of the bed-hold notice was sent with the resident to the hospital, where her sister was supposed to receive it. However, there was no evidence to confirm that the responsible party actually received the written information. This oversight was a violation of the federal regulation 483.15(d)(1)(2) regarding the notice of bed-hold policy before or upon transfer, and it was a repeat deficiency from a previous citation on September 1, 2023.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. For Resident 88, the MDS assessment dated May 29, 2024, incorrectly indicated that the resident was discharged to a hospital setting, while nursing documentation on the same date showed that the resident was discharged home with her husband. This error was confirmed during an interview with the Administrator and Director of Nursing on August 29, 2024. For Resident 2, the MDS assessment inaccurately recorded that the resident was on an antibiotic, despite there being no evidence in the clinical record of antibiotic administration during the assessment period. This discrepancy was confirmed in an interview with the Nursing Home Administrator on August 29, 2024.
Failure to Monitor Weight and Notify Physician
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with congestive heart failure by not adhering to physician-ordered weight assessments. The resident, who was on a fluid restriction and prescribed Lasix, experienced significant weight fluctuations that were not properly monitored or reported to the physician as required. The physician's orders specified daily weight assessments initially, followed by weekly assessments, but these were not consistently implemented. The resident's weight increased significantly over several weeks, leading to symptoms of respiratory distress and eventual hospitalization. Despite a physician's order to notify them if the resident's weight increased by more than five pounds in one week, the staff did not report a 5.8-pound increase in one week or a 9.8-pound increase over two weeks. It was only after the resident exhibited wheezing and a 10-pound weight gain over two weeks that the physician was notified, resulting in an adjustment of the resident's medication. The Nursing Home Administrator and the Director of Nursing confirmed these findings, indicating a lapse in following the care plan and physician's orders.
Failure to Provide Physician-Ordered ROM Services
Penalty
Summary
The facility failed to provide physician-ordered services to maintain a resident's range of motion for two residents. For Resident 23, a clinical record review revealed a physician's order dated October 15, 2023, for the use of a palmar roll on her right hand every evening at bedtime to prevent contracture. The order also required staff to perform skin checks each shift while the palmar roll was worn. However, there was no documentation indicating that the palmar roll was placed nightly or that skin checks were completed. An observation and interview with Resident 23 on August 27, 2024, showed her right hand was contracted, and she reported doing her own physical therapy program. No palmar roll was found in her room. For Resident 40, a clinical record review showed an MDS assessment dated June 4, 2024, indicating no lower extremity impairments. However, a subsequent quarterly MDS assessment revealed bilateral lower extremity impairment. An interview with the Director of Nursing confirmed there was no evidence that the facility assessed Resident 40's decline in lower extremity range of motion. The facility failed to ensure Resident 40 received appropriate treatment and services to maintain or improve her range of motion.
Failure to Obtain Informed Consent and Assess Bed Rail Risks
Penalty
Summary
The facility failed to obtain informed consent and assess the risk of side rail entrapment for two residents, leading to deficiencies in accident hazard prevention. For Resident 12, observations revealed the presence of bilateral one-quarter enabler bars on the bed, despite therapy's assessment indicating they were unnecessary. Maintenance staff evaluated the bars for potential entrapment, but there was no documentation of consent from Resident 12 or their responsible party, nor evidence of education provided regarding the risks. Additionally, the nursing staff did not assess the need for enabler bars concerning entrapment zones. A facility note later confirmed that Resident 12 should not have had enabler bars, and the resident's request for them was not communicated to nursing or therapy. For Resident 66, a side rail was observed on the left side of her bed. Although nursing documentation indicated consent was obtained from Resident 66, a physician's order noted her incapacity to understand her rights and responsibilities. The facility could not provide evidence of informed consent from Resident 66's responsible party or a side rail entrapment risk assessment. The Bed System Measurement Device Test Results Worksheets lacked specific resident information, making it unclear if the bed's dimensions were appropriate for Resident 66. The facility confirmed that these worksheets do not become part of the residents' medical records, and no informed consent was provided for the use of the side rail.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that all nurse aide staff completed the required minimum of 12 hours of in-service education training annually. This deficiency was identified during a review of facility staff education records and staff interviews. Specifically, two nurse aides, Employee 1 and Employee 2, did not meet the training requirements. Employee 1, who was hired on January 10, 2017, completed only 7.25 hours, and Employee 2, hired on June 5, 2023, completed only 9.0 hours of the required training. The training was supposed to include dementia care, abuse prevention, and address any areas of weakness or special care needs of residents. This was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing.
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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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