Camp Hill Skilled Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Camp Hill, Pennsylvania.
- Location
- 1700 Market Street, Camp Hill, Pennsylvania 17011
- CMS Provider Number
- 395440
- Inspections on file
- 23
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Camp Hill Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
Surveyors found that multiple residents’ rooms were not maintained in a safe, clean, and homelike condition, despite facility policy requiring such an environment. Observations over two consecutive days showed damaged walls, baseboards pulling away from walls, stained ceiling tiles, and holes above a bed in one room, while other rooms had persistently dirty tray tables and floors, as well as damaged walls and baseboards. The NHA acknowledged these environmental concerns and stated an expectation that housekeeping and maintenance services maintain a sanitary, orderly, and comfortable interior.
Residents with physician-ordered consistent carbohydrate diets for diabetes were not provided foods consistent with their prescribed therapeutic diets. Facility policy and diet extension sheets required that residents on a consistent carbohydrate diet receive diet angel food cake instead of regular angel food cake, but during a lunch meal service, residents on these diets were observed receiving the same regular angel food cake as those on liberalized diets. The Dietary Manager confirmed that no differentiation was made between diet orders, and product labeling showed the cake contained significant sugar and carbohydrates, contrary to the intended diet extension.
Surveyors identified multiple failures to follow professional food service standards, including undated open dry goods, expired bread products with visible mold, and cereal, sugar, and thickener stored past their labeled use-by dates, with scoops left inside bulk bins. Reach-in refrigerators and freezers were heavily soiled, some foods in cold storage were undated or past their use-by dates, and one freezer was operating above required temperature after being left open. An open beverage container lacked an open date, and dish machine temperature logs for several months were missing, despite leadership expectations that food storage, labeling, and equipment sanitation comply with policy and regulatory requirements.
A resident with major depressive disorder and dementia was started on Zoloft and Olanzapine for depression and psychotic behaviors without the facility obtaining and documenting informed consent as required by its policy. The care plan identified the resident as being at risk for complications related to psychotropic drug use, yet the clinical record lacked any documentation that the risks and benefits of these medications were explained to the resident or representative. The DON confirmed that appropriate notifications were not made before initiating the psychotropic medications.
Surveyors found that the facility did not provide required Medicare coverage and non-coverage notices to three residents when their Medicare A skilled stays ended. Record review showed that two residents who continued care after Medicare A ended were not given the SNF-ABN to explain which services were no longer covered and the related costs, and another resident discharged home was not given the NOMNC to indicate that the Medicare A stay was ending. The NHA confirmed that these required beneficiary notifications were not issued.
A resident with cirrhosis, CKD, and dementia was readmitted from the hospital, and multiple discrepancies occurred between the hospital d/c medication orders and the facility’s active orders. The consultant pharmacist identified transcription errors involving lactulose, tamsulosin, bumetanide, and levothyroxine dosing. The DON reported that an RN completed the readmission medication review using the resident’s pre-hospital medication list instead of the hospital d/c orders, leading to the resident not receiving care in accordance with professional standards of practice.
A resident with polyneuropathy, hypertension, and a right heel pressure ulcer was not consistently provided with ordered pressure-relieving devices and complete wound care. Observations showed the resident in bed without a heel-float boot or heel offloading, while the TAR documented that the boot was in use every shift. The resident reported staff rarely applied the boot and that it was kept in the closet. Wound assessment recommendations for bilateral heel-float boots and a dietitian consult were not documented as implemented, and the wound care order for Santyl ointment did not include the recommended secondary dressings. The NHA and DON acknowledged they would expect the heel boot use and wound recommendations to be correctly carried out.
A resident with COPD and obstructive sleep apnea was observed in bed receiving oxygen at 2 L/min via nasal cannula without a current physician order, despite facility policy requiring order verification before implementing supplemental oxygen. Record review showed a care plan addressing respiratory complications but no active oxygen order, and the DON confirmed that a prior oxygen order had not been renewed.
A resident with dementia, multiple rib fractures, and documented pain had a care plan intervention for pain medication and a physiatry order for a routine 4% lidocaine patch intended for the ribs, but the physician’s orders did not specify the application site. On multiple days the lidocaine patch was not administered, with nursing notes stating the order lacked placement details and the resident could not indicate where it should go. On days when the patch was given, documentation showed it was applied to various body sites such as the hip, arm, thigh, back, deltoid, and abdomen, with no documentation of rib application. The DON reported she expected the order to include patch placement and for it to be administered as ordered.
A resident with PTSD and major depressive disorder, and a documented history of childhood abuse, was evaluated by psychiatry, which recorded the resident’s trauma history and preference to avoid male caregivers. Facility policy required identification of trauma triggers and inclusion of trigger-specific interventions in the care plan. However, the resident’s care plan, developed for fluctuating mood symptoms related to anxiety and PTSD, did not include the preference to avoid male caregivers or any identified trauma triggers, despite a positive trauma screen and available psychiatric documentation.
A resident with major depressive disorder and dementia had pharmacist recommendations related to PRN pain medication parameters and appropriate dosing documented in the clinical record, but the attending physician did not review, act on, or document any response to these identified irregularities. Facility policy required that recommendations needing physician intervention be addressed by the physician, and the DON confirmed the expectation that physicians review and document actions and rationale for MRR findings, which did not occur in this case.
A resident with acute kidney failure and diabetes was observed with an unlabeled tube feeding solution at bedside. The solution lacked information on contents, staff initials, and date/time hung, and staff could not confirm what was being administered. Facility policy did not specify labeling requirements, and the Nursing Home Administrator acknowledged the expectation for proper labeling.
A resident with a pressure ulcer and chronic kidney disease was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. During a dressing change, an LPN wore only gloves and did not use a gown, and there was no EBP signage or physician order in place. Staff confirmed that EBP had not been initiated for the resident.
A resident with significant physical limitations and a care plan requiring two-person assistance for ADLs was provided incontinence care by a single nurse aide, who was unaware of the care requirements. This resulted in the resident falling from bed and sustaining a right hip fracture, necessitating hospital transfer.
A resident with a history of stroke, above-the-knee amputation, and diabetes was care planned for a two-person assist with ADLs due to physical limitations. However, a CNA provided incontinence care alone, contrary to the care plan, resulting in the resident falling from the bed and sustaining a right hip fracture. The CNA was unaware that incontinence care was considered an ADL requiring two-person assistance, and the care plan instructions were not followed.
The facility did not maintain the smoke resistance of hazardous area enclosures, affecting one of seven smoke compartments. The 3rd floor door to the Soiled Utility Room, near a resident room, failed to latch properly. This was confirmed by the Senior Maintenance Director.
The facility failed to maintain the automatic sprinkler protection system, affecting one smoke compartment. Observations revealed missing escutcheons on sprinkler heads in the Clean Utility Room, Arcadia Restroom, and Ice Machine Room on the first floor. The Senior Maintenance Director confirmed the deficiency.
The facility failed to ensure the positive latching of a corridor door on the 3rd floor, affecting one of the smoke compartments. During an observation, it was found that the door to the Sun Room did not latch properly, as confirmed by the Senior Maintenance Director. This deficiency violates NFPA 101 standards and CMS regulations for corridor doors.
The facility failed to maintain the smoke resistance of smoke barrier walls, as observed with an unprotected penetration on the 2nd floor above the ceiling near the T.V. Lounge. The Senior Maintenance Director confirmed this issue.
The facility failed to provide necessary ADL assistance for three residents, leading to deficiencies in nutrition, grooming, and personal hygiene. A resident with hemiplegia and dementia was left unattended with a meal tray for 20 minutes. Another resident with similar conditions was not offered shaving as part of her grooming care, despite being dependent on staff. A third resident with Alzheimer's was observed with significant facial hair, indicating a lack of grooming assistance. These deficiencies were confirmed through observations and staff interviews.
The facility failed to provide proper pressure ulcer care and infection control for two residents. One resident with chronic conditions was transferred to the hospital with a sacral wound that was not properly evaluated, and another resident with a stage 3 pressure ulcer received a dressing change without proper infection control practices. The facility did not adhere to its policies for wound management and infection control.
The facility failed to provide and document restorative nursing programs for residents with limited mobility. A resident with hemiplegia was observed without a required palm guard, and documentation for their restorative programs was missing. Another resident's program documentation was not captured due to a system change, and a third resident also had missing documentation for their programs. The DON confirmed the lack of documentation and expected the programs to be provided.
The facility failed to follow professional standards for food service safety, with issues in the main kitchen and a nourishment area. The sanitizer solution concentration was not logged, and the dish machine's temperature was below the safe minimum. The Med Bridge pantry had improperly labeled and expired food items. The facility's policies on food labeling and expiration were not adhered to, leading to deficiencies.
The facility failed to provide required written notices to two residents following the end of their Medicare coverage. For one resident, a SNF-ABN was issued only telephonically, while for another, no SNF-ABN was sent. Both residents remained in the facility after their Medicare A coverage ended, and the Nursing Home Administrator could not provide evidence of written notices.
The facility did not ensure the protection of personal property for two residents, one discharged to the hospital and another who passed away. There was no documented inventory or accounting for their personal effects, as confirmed by the DON.
The facility did not report the results of an abuse investigation within the required timeframe. An alleged neglect incident occurred, and the investigation was completed, but the results were submitted late due to the DON's illness. The Administrator was expected to submit the report in the DON's absence.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in medication documentation. One resident's MDS inaccurately indicated anticoagulant use, while another's MDS had incorrect dates for antipsychotic medication management. These errors were confirmed by the DON.
The facility failed to develop comprehensive care plans for two residents, one with anxiety and depression medications and another self-administering nebulizer medications. The care plans did not address the management of these medications, as confirmed by the DON.
A facility failed to involve a resident with chronic conditions in care planning and did not update another resident's care plan to include physician-ordered Prevalon boots for stroke-related conditions. Staff were unaware of the order, leading to non-implementation, and the resident was not informed of care plan meetings.
The facility failed to notify the MD about a resident's high blood glucose levels and did not conduct regular wound assessments for another resident with MASD. The DON confirmed that the MD should have been informed and that weekly wound evaluations were expected but not performed.
A resident admitted with chronic kidney disease, diabetes, a stage three pressure ulcer, and a Foley catheter did not receive timely physician orders for wound treatment and catheter care. Orders were delayed by five and six days, respectively, contrary to facility expectations.
The facility failed to document the final disposition of medications for two residents upon discharge. One resident's record showed 98 Oxycodone tablets remaining, with only one staff member signing off on disposal, contrary to policy. Another resident's record lacked any documentation of medication disposition. The DON confirmed these deficiencies.
The facility failed to act on a pharmacist's medication recommendations for two residents. One resident with hypertension and anxiety disorder was prescribed Quetiapine Fumarate, and a dose reduction was recommended but not implemented. Another resident with major depressive disorder and dementia was also prescribed Quetiapine Fumarate, with similar recommendations for dose reduction that were not acted upon. The DON expected timely review and implementation of these recommendations.
The facility failed to manage medications properly, with expired COVID tests found in the Arcadia unit medication cart and undated insulin pens and a protein supplement in the 3rd floor short hall cart. An LPN and a Graduate Practical Nurse confirmed these deficiencies, and the DON acknowledged the failure to adhere to medication management policies.
A facility failed to follow infection control practices during a dressing change for a resident with a stage three pressure ulcer. An employee placed medical grade honey on an unclean surface and returned it to the treatment cart without cleaning or labeling it. The resident had multiple diagnoses, including chronic kidney disease and diabetes. The DON confirmed the expectation to label supplies to prevent cross-contamination.
A resident with a UTI was prescribed ciprofloxacin, but subsequent tests showed resistance to the antibiotic. Despite facility policy requiring adjustment based on sensitivity tests, the medication was not changed, and the ineffective treatment continued without documented rationale. The DON confirmed the expectation to adjust antibiotic use was not met.
The facility did not comply with CDC guidelines for TB screening of new hires. Two nurse aides were not tested for TB upon hire, despite CDC recommendations for a baseline TB risk assessment and testing. The Nursing Home Administrator indicated the facility did not require a new test if one was done within a year, contrary to CDC guidelines.
The facility did not comply with dietary regulations by failing to post or distribute menus to residents at least two weeks in advance. Observations showed only the current week's menu was available, and interviews with residents confirmed they did not receive menus in advance. The Nursing Home Administrator expected compliance with this requirement, which was not met.
The facility failed to administer medications on time for several residents, with LPNs administering doses hours later than prescribed. Residents with conditions such as diabetes, hypertension, osteoarthritis, and Parkinson's disease received their medications late, contrary to physician orders. Interviews with the NHA and DON confirmed the expectation for timely administration, highlighting deficiencies in the facility's medication management practices.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on one of three nursing units, contrary to its policy titled "Safe and Homelike Environment" last reviewed January 5, 2026. That policy states that residents have the right to a safe, clean, comfortable, and homelike environment and that the center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During observations of one resident’s room on two consecutive days, surveyors noted damaged wall areas in a corner, baseboard pulling away from the wall, four ceiling tiles with brown stains, and holes in the wall above the bed, with no change between the first and second day. Additional observations on the same unit showed similar failures to provide adequate housekeeping and maintenance. In another resident’s room, the tray table was dirty with spilled liquid and the floor around the bed was dirty on two consecutive days, with conditions unchanged. A third resident’s bedside table was dirty with several rings from beverage cups and the floor underneath the table was dirty on both days, again without improvement. A fourth resident’s room had a baseboard coming away from the wall and damaged wall surfaces, also observed on two consecutive days with no change. During an interview, the Nursing Home Administrator acknowledged the environmental concerns in these rooms and stated an expectation that the facility provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment.
Failure to Follow Consistent Carbohydrate Diet Extensions for Diabetic Residents
Penalty
Summary
The facility failed to ensure that residents on physician-ordered consistent carbohydrate diets received foods in the appropriate form and nutritive content as specified by the therapeutic diet extensions. Facility policy titled "Consistency Alterations and Therapeutic Menus" stated that the regular/liberalized menu would be extended for therapeutic diets, including consistent carbohydrate diets, to provide diets as ordered by the physician/APP. The facility’s diet extension sheet for a specific lunch meal indicated that residents on a regular/liberalized diet should receive a slice of angel food cake, while residents on a consistent carbohydrate diet should receive a slice of diet angel food cake. However, during observation of the tray line meal service, multiple residents on consistent carbohydrate diets for diabetes were served regular angel food cake instead of the diet version. Review of physician orders showed that six observed residents, as well as numerous additional residents, were ordered consistent carbohydrate diets for diabetes. Despite these orders and the diet extension sheet, the Dietary Manager confirmed that the same angel food cake was served across all diet orders, without differentiation for the consistent carbohydrate diet. Review of the nutrition facts and ingredients label for the angel food cake served revealed it contained 28 grams of total carbohydrates and 20 grams of sugar, with sugar listed as the primary ingredient and no sugar substitutes present. The Nursing Home Administrator stated that he would expect therapeutic diets to be provided as ordered and for extension sheets to be followed for therapeutic diet alterations.
Improper Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
The deficiency involves failure to store food and maintain kitchen equipment in accordance with professional standards and the facility’s own policies. Surveyors reviewing the facility’s “Food Storage: Cold Foods” policy noted requirements for proper temperature control, labeling, dating, and prevention of cross-contamination. During observation of the dry storage area, they found multiple open containers and packages of food, including ziti pasta, fettucine pasta, croutons, dinner rolls, and hot dog buns, that were not dated with an open date. Several hot dog bun packages were past their use-by dates, and two packages showed spots consistent with mold. In the main kitchen, four bins of assorted cereal and a bin of sugar were found with use-by dates that had already passed. A bin of thickener was labeled with an older date, was caked with debris, contained a scoop stored inside, and had black specks throughout the powder. The sugar bin also had a scoop stored inside. The Dietary Manager stated that scoops should not be stored inside the thickener and sugar bins and that these bins should be replenished and cleaned at least every two months. Additional observations showed that cold storage and equipment cleanliness were not maintained as required. Reach-in Refrigerators 1 and 3 had bottoms and sides that were heavily soiled with debris and spill marks, and Reach-in Freezer 3 was also heavily soiled. In Reach-in Refrigerator 2, a bin of turkey sausage was dated with a use-by date that had already passed, and a bin of carrots was not dated. In Reach-in Refrigerator 3, an open container of strawberry lemonade lacked an open date; the Dietary Manager acknowledged it should be discarded and that all open food and beverage containers should be labeled with an open date. In Reach-in Freezer 1, three bags of mixed vegetables were not dated, and the temperature gauge read 17°F, above the policy requirement of 0°F or below; the Dietary Manager reported the freezer had been left open for about 30 minutes. On a return visit, Reach-in Refrigerators 1 and 3 appeared to have been cleaned but still had debris and spill marks. Review of 2025 dish machine temperature logs showed that logs for October, November, and December could not be located. The Nursing Home Administrator and Dietary Manager both stated expectations that food be stored, labeled, dated, and equipment cleaned and utilized in accordance with professional standards and facility policy.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, prior to administering psychotropic medications to a resident. Facility policy NSG206 Behaviors; Management of Symptoms, revised September 25, 2025, required staff to obtain consent when medication is ordered for behavioral symptoms. Resident 4 had diagnoses including major depressive disorder and dementia, and physician orders showed Zoloft 25 mg by mouth at bedtime for depression starting January 29, 2026, and Olanzapine 5 mg at bedtime for psychotic behaviors starting December 21, 2025. The resident’s care plan identified a focus that the resident was at risk for complications related to the use of psychotropic drugs, created on December 22, 2025. Review of the resident’s medical record did not reveal any documentation of an explanation of the risks and benefits of these psychotropic medications or consent for their use by the resident or their representative. In an interview, the Director of Nursing confirmed that the appropriate notifications were not made prior to starting the psychotropic medications for this resident. This deficiency was cited under 211.12(d)(1)(3)(5) Nursing services.
Failure to Provide Required Medicare Coverage and Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that residents were informed of items and services included in nursing facility services for which they may not be charged, and of other items and services for which they may be charged and the amounts, when Medicare Part A coverage ended. For one resident admitted in late November 2025, census information showed a Medicare A coverage period that ended on December 23, 2025. Review of this resident’s Skilled Nursing Facility Beneficiary Notification Review form showed the required Skilled Nursing Facility-Advance Beneficiary Notice of Non-Coverage (SNF-ABN) was not provided to inform the resident of the cost of items and services no longer covered under Medicare A. Another resident admitted in mid-December 2025 had Medicare A coverage that ended in mid-January 2026 upon discharge home, and review of that resident’s Skilled Nursing Facility Beneficiary Notification Review form revealed the required Notice of Medicare Non-Coverage (NOMNC) was not provided to indicate that the stay was no longer covered under Medicare A. A third resident admitted in early August 2025 had a Medicare A coverage period that ended in late October 2025. Review of this resident’s Skilled Nursing Facility Beneficiary Notification Review form showed the required SNF-ABN was not provided to inform the resident of the cost of items and services no longer covered under Medicare A and the cost of those items and services. In an interview on February 24, 2026, at 12:15 PM, the Nursing Home Administrator confirmed that the facility had not provided these residents with the required Medicare coverage and non-coverage notices, as required under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Medication Reconciliation Errors After Hospital Readmission
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident when reconciling medications after a hospital stay. The facility’s person-centered care plan policy required that care and services be provided according to accepted standards of clinical practice. The resident had diagnoses including cirrhosis of the liver, chronic kidney disease, and dementia, and experienced multiple hospital transfers, including a discharge from the hospital and readmission to the facility. After the resident’s return, the consultant pharmacist’s progress note dated November 4, 2025, identified transcription errors between the hospital discharge medication orders and the current facility orders. These discrepancies included lactulose ordered at 30 ml three times daily on the hospital discharge summary but ordered once daily at the facility, tamsulosin ordered at 0.4 mg once daily on discharge but ordered as 0.8 mg (two capsules) at the facility, and bumetanide ordered at 1 mg twice daily on discharge but ordered as 0.5 mg twice daily at the facility. Further review of the monthly consultant pharmacy recommendations dated November 20, 2025, showed that the hospital discharge summary ordered levothyroxine 37.5 mcg by mouth once daily, but on November 3, 2025, it had been ordered twice daily at the facility, despite this medication typically being dosed once daily. In an interview, the DON stated that the RN responsible for readmission medication reconciliation did not have the hospital discharge record and instead used the resident’s pre-hospitalization medication list when reviewing medications with the physician at readmission. The DON indicated that the RN should have used the hospital discharge medication orders to review with the physician and to update the resident’s clinical record, rather than relying on the medication list from before the hospitalization. These actions and omissions resulted in the resident not receiving treatment and care according to the hospital discharge orders and accepted professional standards of practice.
Failure to Implement Ordered Pressure Ulcer Interventions and Wound Care Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive care for a resident with a right heel pressure ulcer and risk for further skin breakdown. The resident had diagnoses including polyneuropathy and hypertension and had a care plan focus indicating risk for skin breakdown related to a right heel pressure ulcer, with an intervention to wear a prevalon boot to the right foot when in bed. A wound assessment dated January 15, 2026, recommended a dietitian consultation and the use of heel-float boots to both feet while in bed to offload the heels. The facility could not provide documentation that the recommended dietary consultation was requested or completed, and the most recent dietary consult in the record was from September 29, 2025. Multiple observations on February 24 and 25, 2026, showed the resident lying in bed without a heel-float boot and without pillows under the foot, despite a treatment administration record (TAR) order for right heel boots to be on at all times except during care. The resident reported that he hardly ever wore the right heel boot because staff did not place it on him and that the boot was in his closet. Review of the January 2026 TAR showed an order for Santyl ointment to the right heel daily for the pressure ulcer, but the order did not include the secondary dressings (Vashe-moistened gauze and foam) that had been recommended in the January 22, 2026 wound assessment. The February 2026 TAR documented that the resident was wearing a right heel boot every shift on the dates when surveyors observed that the boot was not in place. In an interview, the Nursing Home Administrator and DON stated they would expect the resident to be wearing the heel boot as ordered, and for wound assessment recommendations and wound orders to be correctly implemented.
Oxygen Therapy Provided Without Current Physician Order
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory services in accordance with professional standards of practice for one resident who required supplemental oxygen. The facility’s policy for oxygen concentrator use, revised August 7, 2023, requires verification of a physician’s order when implementing supplemental oxygen. Clinical record review for Resident 97, who had diagnoses including COPD and obstructive sleep apnea, showed a care plan for risk of respiratory complications related to recent hospitalization and COPD, but review of current physician orders did not reveal an active order for supplemental oxygen. During observation, the resident was found lying in bed wearing a nasal cannula and receiving oxygen at 2 L/min despite the absence of a current physician order. In an interview, the DON stated that the resident previously had an order for supplemental oxygen, but it had not been renewed.
Failure to Clarify and Administer Lidocaine Patch for Pain as Ordered
Penalty
Summary
The facility failed to provide pain management in accordance with professional standards, the resident’s person-centered care plan, and the resident’s goals and preferences for one resident. The resident had diagnoses including hypothyroidism and dementia and a care plan identifying risk for altered comfort related to impaired mobility, multiple left rib fractures, polyneuropathy, and pain, with an intervention to medicate for pain as ordered and monitor for effectiveness and side effects. A physiatry progress note documented that the resident’s pain was not well controlled and ordered a routine lidocaine patch to the ribs. Physician orders for a 4% lidocaine external patch directed staff to apply the patch once daily for pain but did not specify the anatomical site of application, despite the intent for rib placement. Review of treatment administration records showed multiple dates on which the lidocaine patch was not administered as ordered. Nursing progress notes repeatedly documented that the patch was not given because the order lacked directions on where to apply it and the resident, due to dementia, was unable to indicate the site. On several other dates when the patch was administered, documentation showed it was applied to various locations including the right hip, right arm, right thigh, left hip, lower back, right deltoid, and once to the lower left abdominal quadrant, with no documentation of application to the ribs. The DON stated she would have expected the order to specify patch placement and for the medication to be administered as ordered.
Failure to Incorporate Known Trauma Trigger and Care Preference Into Care Plan
Penalty
Summary
The facility failed to provide trauma-informed, culturally competent care by not incorporating a known trauma trigger and related preference into a resident’s care plan. Facility policy on Trauma Informed Care and Culturally Competent Care required the center to identify triggers that may re-traumatize patients with a history of trauma and to add trigger-specific interventions to the care plan to decrease exposure and mitigate effects. The resident’s diagnoses included PTSD and major depressive disorder. Psychiatry notes from two visits documented that the resident had a trauma history of childhood abuse by stepfathers and a stated preference to not have male caregivers. Despite this information, review of the resident’s care plan, initiated for risk of distressed/fluctuating mood symptoms related to anxiety and PTSD, did not include any intervention reflecting the resident’s preference to avoid male caregivers or any identified trauma triggers. A trauma assessment completed later showed a positive trauma screen with a score of 4, but the care plan still lacked documentation of the trigger or related interventions. In an interview, the Nursing Home Administrator stated he would have expected the resident’s trigger of male caregivers to have been added to the care plan and in place, confirming that this had not occurred.
Failure to Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that medication regimen review (MRR) recommendations made by the consultant pharmacist were reviewed and addressed by the attending physician or prescriber for one resident. Facility policy titled "Medication Regimen Review and Reporting," revised January 2024, stated that for recommendations not requiring physician intervention, the DON or licensed designee would address the recommendations, implying that recommendations requiring physician intervention should be addressed by the physician. For Resident 4, who had diagnoses including major depressive disorder and dementia, the consultant pharmacist made specific recommendations related to the resident’s PRN pain medication regimen. Review of Resident 4’s medical record showed that on one occasion the consultant pharmacist recommended adding parameters for the resident’s PRN pain medication, and on another occasion recommended adding an appropriate dose for the resident’s pain medication. In both instances, further review of the record failed to show that the physician had reviewed or taken any action to address these identified irregularities. During an interview, the DON stated an expectation that the regulation would be followed and that the physician would review the irregularities, document any action taken, and document the rationale in the resident’s medical record, which had not occurred for these recommendations.
Failure to Label Tube Feeding Solution for Resident Receiving Enteral Nutrition
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings. Observation revealed that a bottle of tube feeding solution was hanging at the resident's bedside without any labeling to indicate the contents, the initials of the staff member who hung it, or the date and time it was started. The facility's policy on enteral management did not specify requirements for labeling tube feeding solutions with this information. The resident in question had diagnoses including acute kidney failure and diabetes, and had a physician's order for Glucerna 1.5 to be administered at a specific rate. A review of the resident's clinical record confirmed the presence of an order for Glucerna 1.5, and the plan of care noted the use of an enteral feeding tube. During staff interviews, an LPN stated she did not hang the tube feeding solution and was unaware of when it was started or by whom, and could not confirm the contents of the bottle. The Nursing Home Administrator stated that he would expect the tube feeding solution to be labeled with the contents and the time/date it was hung, but this was not done in this instance.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection control policies for a resident who required Enhanced Barrier Precautions (EBP) due to a pressure ulcer on the left heel and chronic kidney disease. According to the facility's policy, residents with wounds or indwelling medical devices should be placed on EBP unless contact precautions are indicated. Observation revealed that there was no signage on the resident's door indicating EBP, and during a dressing change, the LPN only wore gloves and did not use a gown as required for high-contact activities. The resident's clinical record did not include a physician's order for EBP, and staff interviews confirmed that EBP was not in place at the time of the observation.
Failure to Follow Care Plan Results in Resident Hip Fracture
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in actual harm. A resident with a history of cerebral infarction, right above-the-knee amputation, and diabetes mellitus type II required assistance from two staff members for activities of daily living (ADLs), as documented in the care plan and Kardex. During an incident, a nurse aide provided incontinence care alone, contrary to the resident's care plan, which specified a two-person assist for all ADLs. The aide was unaware that incontinence care was considered an ADL and did not recognize the need for a second staff member during the care. As a result of this failure to follow the established plan of care, the resident fell from the bed while being assisted by only one staff member, sustaining an acute right-sided intertrochanteric hip fracture. The resident experienced pain and required transfer to the hospital for evaluation and treatment. The incident was witnessed and documented, and the nurse aide involved confirmed a lack of understanding regarding the required level of assistance for the resident during ADL care.
Failure to Provide Required Assistance During ADL Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident received adequate assistance to prevent falls, resulting in harm. According to the facility's policy, activities of daily living (ADLs), including incontinence care, require adherence to the care plan and appropriate staffing. The resident involved had significant medical conditions, including a history of stroke, above-the-knee amputation, and diabetes, and was care planned for a two-person assist with ADLs due to generalized weakness and physical limitations. Despite this, a nurse aide provided incontinence care alone, without the required second staff member, during which the resident fell from the bed and sustained a right hip fracture. The incident occurred when the resident, while being changed, held onto a chair that moved, causing her to roll off the bed. The nurse aide involved stated she was unaware that incontinence care was considered an ADL and did not realize a two-person assist was required for this task. Documentation in the resident's care plan and Kardex indicated the need for two-person assistance with ADLs, but this was not followed. The nursing home administrator confirmed that staff are expected to know incontinence care is an ADL and to follow the care plan. The failure to provide the required assistance directly resulted in the resident's fall and injury.
Failure to Maintain Smoke Resistance in Hazardous Area
Penalty
Summary
The facility failed to maintain the smoke resistance of hazardous area enclosures, specifically affecting one of seven smoke compartments. During an observation on January 27, 2025, at 10:10 AM, it was noted that the door to the Soiled Utility Room on the 3rd floor, located by Resident Room 307, did not positively latch within the door frame. This deficiency was confirmed through an interview with the Senior Maintenance Director at the same time, who acknowledged that the door failed to latch properly.
Plan Of Correction
1. The door mentioned was repaired on 1/29/25 and now operates and latches properly. 2. The Maintenance Director will conduct an audit on all hazardous area doors to ensure smoke tight doors. 3. Audits will continue monthly thereafter. 4. Findings will be reported to QAPI for review each quarter.
Sprinkler System Deficiency Due to Missing Escutcheons
Penalty
Summary
The facility failed to maintain the hardware components of the automatic sprinkler protection system, which affected one of seven smoke compartments. During an observation conducted on January 27, 2025, between 11:21 AM and 11:26 AM, it was noted that sprinkler heads in specific locations were missing an escutcheon. These locations included the Clean Utility Room next to the Arcadia Front Entrance, the Arcadia Restroom by the Med Prep Room, and the Arcadia Ice Machine Room, all situated on the first floor. An interview with the Senior Maintenance Director confirmed the absence of the escutcheons on the sprinkler heads.
Plan Of Correction
1-A: Completed 1/29/25. Replaced escutcheon for sprinkler head in clean utility room next to Arcadia front entrance. 1-B: Completed 1/29/25. Replaced escutcheon for sprinkler head in Arcadia rest room by med prep room. 1-C: Completed 1/29/25. Replaced escutcheon for sprinkler head in Arcadia Ice Machine room. 2. Maintenance Director completed a comprehensive sweep on 2/3/25 of sprinkler heads throughout the building and will conduct random audits monthly. 3. On 2/4/25, Maintenance Director ordered 10 escutcheons to have on hand to replace as needed. 4. Results will be reported to QAPI each quarter for review and effectiveness.
Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of corridor doors, specifically affecting one of the seven smoke compartments within the component. During an observation conducted on January 27, 2025, at 9:59 AM, it was noted that the door to the Sun Room on the 3rd floor did not positively latch within the door frame. This deficiency was identified through direct observation and was confirmed during an interview with the Senior Maintenance Director at the same time. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, as per the NFPA 101 standards and CMS regulations. The failure of the door to latch properly compromises the safety standards set for corridor doors, which are crucial in preventing the spread of smoke in the event of a fire. The deficiency was observed and confirmed by the facility's Senior Maintenance Director, indicating a lapse in maintaining the required safety standards for corridor doors.
Plan Of Correction
1. The door mentioned was repaired on 1/29/25 and now operates and latches properly. 2. The Maintenance Director will conduct a one-time facility-wide audit on all corridor doors to ensure smoke tight doors and positive latching within the door frame. 3. Monthly audits will be completed to check latching on random corridor doors thereafter. 4. Findings will be reported to QAPI for review each quarter.
Failure to Maintain Smoke Barrier Wall Integrity
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring safety in the event of a fire. During an observation on January 27, 2025, at 10:40 AM, it was discovered that there was an unprotected penetration in the smoke barrier wall on the 2nd floor. This penetration was located above the suspended ceiling, near the cross corridor double doors by the T.V. Lounge, and beneath a sprinkler pipe. The Senior Maintenance Director confirmed the presence of this unprotected penetration during an interview conducted at the same time.
Plan Of Correction
1. The penetration was sealed using an approved through penetration fire stop system on 2/3/25. 2. Maintenance Director will inspect all smoke and fire walls throughout the facility by 2/7/25. Any penetrations found will be sealed using an approved penetration fire stop system. 3. All smoke barrier walls will be inspected quarterly and after any contractor completes work that may impact the walls. 4. Facility will maintain the rating of the smoke barrier walls. 5. Findings will be reported to QAPI for review and discussion.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in nutrition, grooming, and personal hygiene. Resident 20, who has hemiplegia, hemiparesis, aphasia, and vascular dementia, was observed during a lunch meal service where her meal tray was placed in front of her but left covered and unattended for 20 minutes before assistance was provided. Her care plan indicated she required substantial assistance with eating, which was not promptly delivered. Resident 35, diagnosed with hemiplegia, hemiparesis, aphasia, and vascular dementia, was observed with dark facial hair on her upper lip and chin, indicating a lack of grooming. Her care plan noted she was dependent on staff for personal hygiene, yet shaving was not offered as part of her ADL care until she explicitly indicated a desire to be shaved. This oversight was confirmed by the Director of Nursing, who stated that shaving should have been offered as part of her care. Resident 101, with muscle wasting, atrophy, and Alzheimer's disease, was observed with significant facial hair on her chin over several days. Her care plan highlighted a risk for decreased ability to perform ADLs, including grooming, yet shaving was not offered during her shower. The Director of Nursing acknowledged that shaving should have been included in her ADL care. These observations and interviews with staff confirmed the facility's failure to provide adequate ADL assistance to these residents.
Plan Of Correction
1. Resident 35 was offered and assisted with shaving facial hair. Resident 101 was offered and assisted with shaving facial hair. 2. A comprehensive review of current residents who are coded as maximal assist or dependent on the MDS will be conducted to ensure that they are offered to be shaved on their shower days and provided feeding assistance timely. 3. The facility will take further steps to validate the problem does not re-occur by re-educating the licensed nurses and nursing assistants on FTag 677 and nursing policy NSG200 Activities of Daily Living. 4. Compliance will be monitored by the Director of Nursing/Designee using the ADL Care audit through a review of three residents weekly x 3 weeks to monitor if shaving was offered and three residents weekly x 3 weeks for timely feeding assistance. Random Audits will then be completed monthly x 2 to monitor for timely feeding and shaving offered with ADLs. Findings will be reported to the QAA Committee to determine the need for further audits.
Failure in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. Resident 16, who had chronic diastolic congestive heart failure, chronic respiratory failure, and chronic kidney disease, was transferred to the hospital with a sacral wound that was not properly evaluated or documented according to facility policy. The facility's policy required weekly wound evaluations, but these were not consistently completed, and the Director of Nursing confirmed the lack of documentation. Additionally, Resident 16 refused wound care on two occasions before being transferred to the hospital, where the wound was found to be in a moist environment and described as a pressure ulcer. Resident 325, who had stage two chronic kidney disease and diabetes mellitus type II, was admitted with a stage 3 pressure ulcer to the sacrum. During a dressing change observation, Employee 9 did not adhere to enhanced barrier precautions by failing to wear a gown and not performing proper hand hygiene. Employee 9 touched unclean surfaces and handled a marker without changing gloves or performing hand hygiene before accessing the resident's wound dressing. The Director of Nursing confirmed that Employee 9 did not follow the facility's expectations for infection control practices. The facility's failure to adhere to its own policies and procedures for wound management and infection control led to deficiencies in the care provided to Residents 16 and 325. The lack of consistent wound evaluations and improper infection control practices during dressing changes contributed to the facility's inability to promote healing and prevent infection for these residents.
Plan Of Correction
Resident 16 has been discharged from the facility. Resident 325 had a wound evaluation completed. A comprehensive review of current residents with pressure ulcers will be conducted to ensure that weekly wound evaluations are completed and Enhanced Barrier Precautions are followed as per policy. The facility will take the further steps to ensure that the problem does not re-occur by in-servicing licensed nursing on FTag 686 as well as IC308 Enhanced Barrier Precautions. Compliance will be monitored by the Director of Nursing/Designee using the Pressure Ulcer Wound Audit and Enhanced Barrier Audit to review 5 residents weekly x 3 weeks and monthly x 2 months, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.
Failure to Provide and Document Restorative Nursing Programs
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services and assistance to maintain or improve their mobility. This deficiency was identified for three residents who were reviewed for limited range of motion. The facility's policy on Restorative Nursing Guidelines requires documentation of interventions, time spent, and patient tolerance, but this was not consistently followed. Resident 35, who has hemiplegia and hemiparesis following a stroke, was observed multiple times without a required palm guard, and there was a lack of documentation for their Restorative Nursing Programs. The Treatment Administration Records did not include the palm guard as an ordered treatment for January 2025, and there were several instances where the restorative programs were not documented. The DON confirmed the absence of documentation and the expectation that the programs should have been provided. Resident 40, who has muscle weakness and contracture, was discharged from occupational therapy and referred to a Restorative Nursing Program. However, there was no documentation of the program minutes or tolerance due to a change in electronic systems. Resident 50, with hemiplegia and hemiparesis, also had multiple instances where their Restorative Nursing Programs were not documented. The DON confirmed the lack of documentation for both residents and expected the programs to be provided as per facility policy.
Plan Of Correction
Unable to retroactively correct Resident 35's palm guard not being in place. Unable to retroactively correct failure to document Restorative Nursing Programs for Resident 35, Resident 40, and Resident 50. A comprehensive review of current residents with an active order for palm guards will be conducted to ensure that palm guards are in place as ordered. A comprehensive review of current residents with a restorative nursing program will be conducted to ensure that the restorative program has been completed and minutes documented. The facility will take further steps to ensure that the problem does not re-occur by in-servicing all nursing staff on F tag 688 with a focus on palm guards and restorative programming, as well as "Restorative Nursing Guidelines" policy. Compliance will be monitored by the Director of Nursing/Designee using the Palm Guard Audit and Restorative Nursing Program Audit to review 5 residents weekly for 3 weeks, then monthly for 2 months to ensure that palm guards are in place as ordered and that restorative programs are being completed and documented as ordered, with audit results being forwarded to the QAA committee to determine the need for further follow-up/monitoring.
Deficiencies in Food Storage and Equipment Use
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in both the main kitchen and one of the nourishment areas. Observations revealed that the facility did not maintain a log for the concentration of the sanitizer solution in the three-compartment sink, and the dish machine's wash temperature was consistently below the minimum safe temperature of 160 degrees Fahrenheit. Interviews with the Food Service Director confirmed that these logs were not being maintained, and the dish machine's temperature was not being recorded. Additionally, the facility's Med Bridge pantry area refrigerator contained multiple food items from outside sources that were not labeled with dates or names, and some items were found to be rotten. The facility's policies require that food brought in by family or visitors be labeled with the resident's name and the date it was brought in, and that it be discarded after three days. However, observations showed that these policies were not followed, as several items were found without proper labeling or were expired. The Nursing Home Administrator acknowledged that it was the facility's expectation for expired items to be discarded and for food items to be labeled and dated according to policy. The failure to comply with these standards and policies resulted in deficiencies related to food storage and equipment use.
Plan Of Correction
1. All unmarked food items were immediately removed from identified areas. 2. All unmarked thickened liquids and frozen shakes were immediately discarded from identified areas. 3. The Dietary Director immediately completed a comprehensive review of all refrigerators in the facility utilized by staff. 4. Dietary Director or Designee will provide re-education regarding maintaining daily temperature and sanitizer solution logs for the dishwasher machine. 5. Dietary Director or Designee will use logs to monitor the sanitizer levels in the 3 compartment sink and will educate staff on appropriate sanitizer levels of the 3 compartment sink. 6. All staff will be educated on storing and labeling food brought from outside sources at the time the food is stored. 7. Dietary Director or Designee will provide re-education to Dietary Staff regarding proper labels for food storage, thickened liquids and frozen shakes. 8. Compliance will be monitored by the Dietary Director or Designee through audits on temperature logs and sanitizer solution logs, daily for 30 days, and then 3x per week for 3 months. 9. Findings will be reported to the QAA Committee to determine the need for further audits.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notices to residents or their representatives following the end of their Medicare coverage for two residents. For Resident 28, Medicare Part A coverage began on December 9, 2024, and ended on January 6, 2025. Although the facility initiated discontinuation from Medicare Part A coverage, a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) was issued only telephonically, and there was no evidence of a written notice being provided. Resident 28 remained in the facility after the discontinuation of her Medicare A coverage. Similarly, for Resident 108, Medicare A coverage started on October 1, 2024, and ended on October 30, 2024. The facility also initiated discontinuation from Medicare Part A coverage for this resident, but a SNF-ABN notice was not sent at the time. Resident 108 continued to stay at the facility after her Medicare A coverage ended. During an interview, the Nursing Home Administrator could not provide additional evidence that written SNF-ABN notices were given to either resident.
Plan Of Correction
1. SNF-ABN notice provided to Residents 28 and 108 by Social Services Director. 2. DON or Designee will complete a comprehensive review of all current residents to ensure provision of a SNF-ABN notice when applicable. 3. To ensure continuity of care, NHA or Designee will provide re-education to the Social Services Directors on FTag 582 Medicaid/Medicare Coverage Liability Notices. 4. Director of Nursing / Designee will conduct three resident SNF-ABN audits per week for 4 weeks, followed by three resident SNF-ABN audits per month for two months. 5. Results will be reported at Quarterly QAPI Meetings to determine the need for further audits.
Failure to Protect Residents' Property from Loss or Theft
Penalty
Summary
The facility failed to exercise reasonable care for the protection of residents' property from loss or theft for two discharged residents. Resident 105 was admitted to the facility and later discharged to the hospital, but there was no documented inventory or accounting for her personal effects following discharge. Similarly, Resident 106, who passed away at the facility, also had no documented inventory or accounting for his personal effects. During an interview, the Director of Nursing confirmed the absence of documentation regarding the personal effects of both residents.
Plan Of Correction
1. Resident 105 and 106 were discharged from the facility. 2. A comprehensive review of residents that discharged within the last 30 days will be conducted to ensure an inventory of personal effects is documented for all belongings. A review of all current residents will be completed to ensure that an inventory sheet is completed. 3. The facility will take further steps to validate the problem does not re-occur by re-educating the nursing staff on FTag 584, re-educating on the Patient's Personal Property policy and completion of the Inventory Sheet upon admission and verified upon discharge. 4. Compliance will be monitored by the Director of Nursing/Designee using the Homelike Environment audit to ensure that there is a completed Inventory Sheet of the patient's personal belongings upon admission and that it is verified, signed and copied upon discharge through an audit of all discharges weekly x 3 weeks then five audits monthly x 2 months. 5. Results will be reported to the QAA Committee who will determine the need for further audits.
Delayed Reporting of Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an abuse investigation within the specified timeframes as outlined in their policy. According to the facility's Abuse Prohibition policy, the Administrator or designee is required to report findings of all completed investigations within five working days to the Department of Health. An alleged incident of neglect occurred on September 24, 2024, and the facility began an investigation on September 25, 2024, concluding it on September 26, 2024. However, the investigation results were not submitted to the Department of Health until October 7, 2024, which exceeded the five working day requirement. During an interview, the Nursing Home Administrator explained that the delay was due to the Director of Nursing's absence because of illness, and the expectation was that the Administrator should have submitted the report in her absence.
Plan Of Correction
1. The facility can not retroactively correct cited deficiency. 2. A comprehensive review of the reports submitted from the last three months will be completed to ensure the PB-22 reporting form was submitted within five days. 3. The facility will take further steps to validate the problem does not reoccur by re-educating the Administrator / Designees on FTag 609 with a focus on timely PB22 submissions. 4. Compliance will be monitored by the Director of Nursing/Designee using the Reporting audit through two audits weekly x 3 audits. 5. Results will be reported to the QAA Committee who will determine the need for further audits.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For one resident with diagnoses including congestive heart failure and chronic kidney disease, the MDS inaccurately indicated the receipt of an anticoagulant, despite the clinical record showing no prescription or administration of such medication during the assessment reference date (ARD). This error was identified through a review of the resident's clinical records and confirmed by the Director of Nursing (DON). Another resident, diagnosed with bipolar disorder and dementia, had discrepancies in the documentation of their antipsychotic medication management. The MDS inaccurately recorded the dates when a gradual dose reduction was deemed clinically contraindicated, conflicting with the psychiatric visit notes. These errors were confirmed during a staff interview with the Nursing Home Administrator and the DON, who acknowledged the coding inaccuracies in the MDS assessments.
Plan Of Correction
1. MDS correction was completed and submitted for resident 8 to indicate that he did not receive an anticoagulant. MDS correction was completed and submitted for Resident 36 to reflect the most recent date of GDR contraindication. 2. A comprehensive review of current residents will be done to ensure correct coding of anticoagulant use. A comprehensive review of current residents taking an antipsychotic medication will be completed to ensure that the MDS is coded correctly in regards to Gradual Dose Reductions. 3. The facility will take further steps to validate the problem does not reoccur by re-educating the Clinical Reimbursement Coordinators on FTAG 641 accuracy of assessments with focus on anticoagulation therapy and Gradual Dose Reduction coding. 4. Compliance will be monitored by the Director of Nursing/Designee using the MDS Coding Audit through three MDS Assessment audits weekly x 3 weeks to validate that the MDS is coded accurately in regards to anticoagulant use and Gradual dose reductions. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 29, who has diagnoses including hypertension and anxiety disorder, was prescribed medications such as Buspirone for anxiety, Duloxetine for depression, and Enoxaparin as a blood thinner. However, the current care plan for Resident 29 did not include any strategies or actions related to the management of these medications. The Director of Nursing (DON) acknowledged that a baseline care plan should have been in place for these medications. Similarly, Resident 47, diagnosed with chronic obstructive pulmonary disease and heart failure, was found to self-administer nebulizer medications. Despite a nursing progress note indicating that Resident 47 was capable of self-administering and storing medications at her bedside, her care plan did not reflect this practice. The DON confirmed that a baseline care plan should have been developed to address the self-administration and storage of medications for Resident 47. These omissions were identified during a review of the facility's compliance with care planning regulations.
Plan Of Correction
Resident 29's care plan has been updated to address the use of antianxiety, antidepressant, and anticoagulant medication use. Resident 47 is discharged from the facility. A comprehensive review of current residents who self-administer medications, or who take antianxiety, antidepressant, anticoagulant medications will be completed by the Director of Nursing/Designee to ensure that those items are appropriately care planned. The facility will take further steps to validate the problem does not reoccur by re-educating the Unit Managers/RN Supervisors on Ftag 656, Nursing Policy 309 "Medication Self-Administration" and Policy OPS416 "Person-centered care plan." Compliance will be monitored by the Director of Nursing/Designee using the Care Plan Audit. Four audits will be completed weekly x 2 weeks and monthly x 2, and results will be reported to the QAA Committee who will determine the need for further audits.
Failure to Involve Resident in Care Planning and Update Care Plan for Medical Equipment
Penalty
Summary
The facility failed to ensure a resident's right to participate in the care planning process and did not review and revise another resident's care plan as required. Resident 19, who has chronic pain, hypertension, and muscle wasting, was not aware of her care plan meetings. Despite a scheduled meeting and attempts to contact her family, there was no documentation indicating that Resident 19 was invited to participate in her care plan meetings since August 2024. Interviews with staff revealed uncertainty about why the resident was not involved, and the Nursing Home Administrator expected residents to be invited to their care plan meetings. Resident 50, diagnosed with hemiplegia and hemiparesis following a stroke, had a physician's order for Prevalon boots to prevent bedsores, but this was not included in the care plan. Observations showed the boots were present in the resident's room, but staff were unaware of the order, leading to a lack of implementation. The Director of Nursing acknowledged the oversight and confirmed that the care plan should have been updated to include the boots, which were not properly documented or communicated to the staff.
Plan Of Correction
1. Resident 50's care plan has been updated to reflect that Prevalon Boots should be on when in bed. Resident 19's care plan meeting has been rescheduled and she has been invited to it. 2. A comprehensive review of current residents' orders will be completed by the Director of Nursing/Designee to ensure order for Prevalon boots is reflected on the care plan. A comprehensive review of current residents will be reviewed by the Social Services Director to ensure quarterly care plan meetings have been scheduled and that residents were invited to attend. 3. The facility will take the further steps to validate the problem does not reoccur by re-educating the Unit Managers/RN Supervisors and Social Services on FTAG 657 Care plan timing and revision with focus on Care plan meetings and preventative skin care measures. 4. Compliance will be monitored by the Director of Nursing/Designee, using the Care Plan Audit through a review of four residents weekly x 2 weeks and monthly x 2 to ensure accuracy of the resident's comprehensive plan of care and resident participation in care plan meetings. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.
Failure to Notify MD and Monitor Wound Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. Resident 71, diagnosed with peripheral vascular disease and hypertension, had a physician's order to notify the Medical Director if blood glucose levels were outside the specified parameters. However, on multiple occasions, Resident 71's blood sugar levels exceeded the upper limit of 250, yet there was no documentation or evidence that the Medical Director was notified as required. This lack of communication was confirmed during an interview with the Director of Nursing, who acknowledged that the Medical Director should have been informed. Resident 88, diagnosed with chronic obstructive pulmonary disease and heart failure, had an in-house acquired moisture-associated skin damage (MASD) identified on December 9, 2024. Despite the presence of this condition, there was no further documentation or assessment of the wound to monitor its progress. The Director of Nursing indicated that weekly wound and skin evaluations should have been conducted to track the MASD, but this was not done, leading to a deficiency in the care provided to Resident 88.
Plan Of Correction
1. Resident 71 has been discharged from the facility. Wound assessment has been completed for resident 88. 2. A comprehensive review of current residents with orders to call MD for blood glucose level outside of the parameters will be completed to ensure that there is documentation that the provider was notified if BS is outside of the parameters within the last 30 days. A comprehensive review of current residents with identified MASD will be conducted to ensure that there are weekly skin evaluations completed for the last 30 days. 3. The facility will take further steps to validate the problem does not re-occur by in-servicing the Licensed Nurses on Ftag 684 with a focus on physician notifications and weekly wound evaluations. 4. Compliance will be monitored by the Director of Nursing/Designee using the Blood Glucose Audit and Wound Audit through an audit of five residents weekly x 3 weeks and monthly x 2 per each individual concern. Findings will be reported to the QAA Committee to determine the need for further audits.
Failure to Obtain Timely Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that a physician provided necessary orders for a resident's immediate care and needs upon admission. Resident 325, who was admitted from the hospital, had several medical conditions including stage two chronic kidney disease, diabetes mellitus type II, and a stage three pressure ulcer to the sacrum. Upon admission, the resident also had a Foley catheter in place. However, the clinical record review revealed that there were no physician orders for the treatment of the sacral pressure ulcer or the care of the Foley catheter at the time of admission. The deficiency was identified when it was found that the orders for the sacral pressure ulcer treatment were not made until five days after admission, and the orders for the Foley catheter care were not made until six days after admission. This lack of timely physician orders for critical care needs was confirmed during a staff interview with the Director of Nursing, who acknowledged that it was the facility's expectation for such orders to be provided upon admission.
Plan Of Correction
Resident 325 had orders placed for care of the Sacral Pressure Ulcer and Foley Catheter and did not have any adverse effects from the delay in orders. A comprehensive review of all current residents with Pressure Ulcers and/or Foley Catheters will be conducted to ensure that wound treatment orders and Foley catheter orders are in place as ordered by MD. The facility will take further steps to ensure that the problem does not re-occur by in-servicing licensed nursing staff on F Tag 710 with a focus on Pressure Ulcer treatment and Foley catheter orders and re-educating licensed nurses on ensuring that wound care orders and Foley catheter orders are entered on admission. Compliance will be monitored by the Director of Nursing/Designee using Wound Treatment and Foley Catheter Audit to review all new admissions weekly x 3 weeks, then a random audit of 5 admissions monthly x 2 months to ensure that wound treatment orders and Foley catheter orders are in place as ordered, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.
Failure to Document Medication Disposition for Discharged Residents
Penalty
Summary
The facility failed to maintain an accurate accounting of the final disposition of medications upon discharge for two residents. For one resident, who was discharged to the hospital, the clinical record showed that 98 Oxycodone tablets remained at discharge. The facility's policy required that the disposal of controlled substances be documented by two staff members, but in this case, only one staff member signed off on the disposal of the medication. This discrepancy was confirmed during an interview with the Director of Nursing (DON). For another resident, who was discharged to home, there was no evidence in the clinical record of the final disposition of the prescribed Oxycodone medication. The facility's policy mandates that the disposal of controlled substances be documented, but the record lacked this documentation. The DON was unable to provide additional information regarding the final disposition of this resident's medications during an interview.
Plan Of Correction
Facility cannot retroactively correct cited deficiency. A Comprehensive review of residents who have been discharged from the facility in the last 30 days will be conducted to ensure that "disposition of medication" form has been completed with 2 Licensed nurse signatures. The facility will take the further steps to ensure that the problem does not re-occur by in-servicing Licensed nursing staff on F Tag 755 with focus on disposition of medications as well as Facility policies, "Disposal of Medication Waste" and "Collection Receptacles for Disposal of Medications". Compliance will be monitored by the Director of Nursing / Designee using the Disposition of Medications audit form to ensure that disposition of medications were completed with 2 nurse signatures. Will review 5 discharged residents weekly x 3 weeks then monthly x 2 months, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.
Failure to Act on Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that the licensed pharmacist's report of medication irregularities was reviewed and acted upon in a timely manner for two residents. Resident 29, who had diagnoses including hypertension and anxiety disorder, was prescribed Quetiapine Fumarate for anxiety, depression, and insomnia. A Medication Regimen Review (MRR) conducted on August 11, 2024, recommended a trial dose reduction of Seroquel. However, the recommendation was not signed by the physician until October 31, 2024, and was never implemented as of January 14, 2025. The Director of Nursing (DON) expressed that the MRR should have been responded to and implemented timely. Similarly, Resident 74, diagnosed with major depressive disorder, anxiety disorder, and dementia, was prescribed Quetiapine Fumarate for depression. An MRR on August 8, 2024, recommended evaluating the routine antipsychotic use for potential dose reduction or discontinuation, and another MRR on August 11, 2024, suggested a trial dose reduction. The physician agreed with the recommendation on October 29, 2024, but the recommendation was not implemented by January 14, 2025. The DON indicated that MRRs should be reviewed and implemented timely by nursing and/or the physician.
Plan Of Correction
DRR for resident 29 with date of 8/11/24 was reviewed by MD and order was placed. DRR for resident 74 with date of 8/8/24 and 8/11/24 were reviewed by MD and orders placed. A Comprehensive review of DRR for the last 2 months will be reviewed to ensure that the MD has reviewed and any new orders implemented. The facility will take further steps to ensure that the problem does not re-occur by in-servicing Unit managers / RN Supervisors on F Tag 756 and facility policy "Medication Regimen Review". Compliance will be monitored by the Director of Nursing / Designee through the DRR Audit of 5 residents weekly x 3 weeks then monthly x 2 months to ensure that the DRR recommendations were reviewed with MD and acted upon, with audit results being forwarded to the QAA committee to determine the need for further follow up / monitoring.
Expired and Improperly Labeled Medications Found in Facility
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by the presence of expired and improperly labeled medications in their medication carts. During an observation of the Arcadia unit medication cart, an unopened box of OHC COVID tests with an expiration date of December 30, 2023, was found. Employee 2, an LPN, confirmed the tests were expired and indicated they would be discarded. Additionally, on the 3rd floor short hall medication cart, two insulin degludec pens, one insulin aspart pen, and a bottle of Medline Liquid Active Protein supplement were found without open dates indicated. Employee 3, a Graduate Practical Nurse, confirmed these items were not dated when opened. The facility's policy on the storage of medications requires that insulin vials and pens be dated when first used and that outdated medications be immediately removed from stock and disposed of according to procedures. The Director of Nursing (DON) confirmed during interviews that the COVID tests should have been discarded and that the insulin pens should have been dated when opened. The DON also confirmed that the liquid protein should have been dated when opened, acknowledging that medications with a shortened shelf life after opening should be dated. These findings indicate a failure to comply with the facility's medication management policies, as well as state regulations regarding pharmacy services.
Plan Of Correction
Expired COVID test kit from Arcadia was discarded. Insulin Degludec pen, Insulin Aspart pen, and Medline Liquid Active Protein on Third Floor were discarded. A Comprehensive review of medication carts will be conducted to ensure that all Insulin Pens and Medline Liquid Active Protein are dated when opened and that there are no expired COVID test kits. The facility will take further steps to ensure that the problem does not re-occur by in-servicing all licensed nursing staff on F Tag F761 with a focus on Insulin Pens and Medline Liquid Active Protein as well as expired medications. Compliance will be monitored by the Director of Nursing / Designee using the Label/Storage of Drugs Audit through 5 random audits weekly x 3 weeks then monthly x 2 months to ensure that there are no expired COVID kits and Insulin Pens/Medline Liquid Active Protein has an open date, with audit results being forwarded to the QAA committee to determine the need for further follow up / monitoring.
Infection Control Deficiency in Dressing Change Procedure
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a dressing change for a resident with a stage three pressure ulcer. Employee 9 retrieved a box of medical grade honey from the treatment cart and placed it on an unclean surface, the resident's bedside table, before using it for the dressing change. After completing the dressing change, Employee 9 returned the honey to the treatment cart without cleaning it or labeling it with the resident's name, which is against the facility's infection control policy. The resident involved had multiple diagnoses, including stage two chronic kidney disease, diabetes mellitus type II, and a stage three pressure ulcer. The Director of Nursing confirmed that the facility's expectation was for Employee 9 to label the medical grade honey with the resident's name to prevent its use on other residents. This oversight in infection control practices was identified during a survey, highlighting a deficiency in the facility's adherence to its infection prevention and control program.
Plan Of Correction
1. Medical Grade Honey has been discarded. 2. A comprehensive review of current residents with an order for Medical Grade Honey will be conducted to ensure that it is labeled with resident name. A comprehensive review of current licensed nursing staff will be conducted to ensure that competency for Aseptic Wound techniques was completed. 3. The facility will take further steps to ensure that the problem does not re-occur by in-servicing licensed nursing staff on F Tag 880 with a focus on aseptic wound techniques. 4. Compliance will be monitored by the Director of Nursing/Designee through 5 random audits weekly x 3 weeks, then monthly x 2 months to ensure that Medical Grade Honey has resident name and through 3 random direct observation audits of nurses performing aseptic dressing changes to ensure that nurses are adhering to Aseptic Wound Techniques, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of congestive heart failure, was prescribed ciprofloxacin based on a urinalysis indicating a possible UTI. However, subsequent urine culture and sensitivity tests revealed that the bacteria were resistant to ciprofloxacin and other antibiotics initially considered. Despite this, there was no change in the resident's medication, and the ciprofloxacin treatment continued without documented clinical rationale. The facility's policy required monitoring and adjusting antibiotic use based on sensitivity tests, a process overseen by the Medical Director and Consultant Pharmacist. However, the laboratory results indicating resistance were not reviewed or acted upon, leading to the continued use of an ineffective antibiotic. The Director of Nursing acknowledged that the facility's expectation was to adjust antibiotic use according to sensitivity tests, which was not done in this case.
Plan Of Correction
1. Resident 98 did not have any adverse effects related to the antibiotic that was administered. Urine culture sensitivity results were reviewed with the MD who advised to not repeat the UA as resident was asymptomatic and already completed the ordered antibiotic. 2. A Comprehensive review of all current residents on an antibiotic for a positive Urinary Tract Infection will be reviewed to ensure that Culture results have been reviewed with the MD timely and that appropriate Medication is in place. 3. The facility will take further steps to ensure that the problem does not re-occur by in-servicing licensed nursing staff on F Tag 881 with a focus on UTI's/Antibiotics as well as facility policy IC 402 Antibiotic Stewardship. 4. Compliance will be monitored by the Director of Nursing / Designee using an Antibiotic Stewardship Audit to review 5 residents weekly x 3 weeks then monthly x 2 months to ensure that UA results were reviewed with MD timely and correct Antibiotic is in place, with audit results being forwarded to the QAA committee to determine the need for further follow up / monitoring.
Non-compliance with CDC TB Screening Guidelines for New Hires
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention's (CDC) guidelines for tuberculosis (TB) screening and testing of new employees. According to the CDC's guidance, all U.S. healthcare personnel should undergo TB screening upon hire, which includes a baseline individual TB risk assessment, TB symptom evaluation, a TB test (either a blood test or skin test), and additional evaluation for TB disease as needed. The facility's policy also mandates TB screening for new employees, including a symptom evaluation, an individual TB risk assessment, and a screening test for those without documented prior TB disease or latent TB infection. However, the facility did not follow these guidelines for two of the five new hires reviewed. Employee 5, a nurse aide hired in September 2024, had a TB skin test completed in September 2023 but did not have a TB test upon hire as required. Similarly, Employee 6, another nurse aide hired in December 2024, had a TB skin test completed in September 2024 but also did not have a TB test upon hire. During an interview, the Nursing Home Administrator stated that the facility was not requiring another skin test if one had been done within a year of hire, which is not in compliance with the CDC's guidelines.
Plan Of Correction
1. CDC recommendations were not followed for screening, testing and surveillance for TB. DON provided TB testing and assessment and symptom evaluation for Employee #5 and Employee #6. 2. Human Resources Director or Designee will complete a comprehensive review of all new hire staff from the last 30 days to ensure TB testing, assessment and screening for symptoms is current. 3. Human Resources Director or Designee will provide re-education to management staff regarding CDC guidelines and the facility policy on "Tuberculosis Screening." 5. Human Resources Director or Designee will complete an audit of new hire employees 3x per week for 3 months to ensure compliance. 6. Findings will be reported to the QAA Committee to determine the need for further audits.
Failure to Provide Menus in Advance
Penalty
Summary
The facility failed to comply with dietary services regulations by not posting or distributing menus to residents at least two weeks in advance. During an initial tour of the facility, it was observed that only the menu for the current week was available on all three skilled nursing units. Interviews with four residents revealed that they did not receive copies of the menus two weeks in advance. Additionally, the Nursing Home Administrator acknowledged the expectation for dietary services to post or distribute menus in advance, which was not being met.
Plan Of Correction
Two weeks of menus were immediately posted for residents. 2. Dietary Director or Designee will provide education regarding the requirement for two weeks of menus to be posted. 3. Compliance will be monitored by the Dietary Director or Designee through audits on two weeks in advance menu posting, daily for 30 days, and then 3x per week for 3 months. 4. Findings will be reported to the QAA Committee to determine the need for further audits.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards of practice, as evidenced by the late administration of medications for several residents. Observations and interviews revealed that Licensed Practical Nurses (LPNs) were administering morning medications well past the scheduled times, with some doses being given hours later than prescribed. This was particularly evident on the third floor and the Arcadia unit, where LPNs were still administering morning medications late into the morning and early afternoon. Resident 4, who has a history of diabetes mellitus type II and neuropathy, received their gabapentin doses significantly later than the prescribed times on multiple occasions. Similarly, Resident 9, diagnosed with hypertension and heart failure, was administered Coreg outside of the physician-ordered parameters, with doses given late and without regard to the required blood pressure checks. Resident 10, with generalized osteoarthritis and vascular dementia, also received acetaminophen doses late, and Resident 12, diagnosed with Parkinson's disease and dementia, experienced similar issues with the timing of their carbidopa-levodopa medication. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the expectation was for medications to be administered at the prescribed times and according to physician orders. However, the facility's failure to adhere to these standards resulted in the identified deficiencies, affecting the care and services provided to the residents involved.
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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