Capitol Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisburg, Pennsylvania.
- Location
- 4000 Linglestown Road, Harrisburg, Pennsylvania 17112
- CMS Provider Number
- 395372
- Inspections on file
- 33
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Capitol Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure ordered medications were available and administered as prescribed for several residents, including those with depression, bipolar disorder, diabetes, COPD, glaucoma, and post-amputation wound care. MARs showed multiple doses of psychotropics, antibiotics, antidiabetics, ophthalmic drops, and inhaled medications as held, blank, or not administered, with nursing notes repeatedly citing that medications were on order, unavailable, or awaiting pharmacy delivery following hospital admissions. In interviews, the NHA first stated that medications would be available at admission but later acknowledged that medications might not always be available as ordered and that providers would be notified when this occurred.
A resident who is continent and typically independent with daytime toileting reported that an LPN placed her on a bedpan intended for her roommate and left the room, after which the resident remained on the bedpan with the call bell activated until she removed it herself. The resident stated she reported this incident the same day to the Admissions Director and Social Worker and asked to speak with the NHA. Both staff members acknowledged being told of the concern, but neither documented the complaint, and the grievance was not entered into the facility’s grievance log or the resident’s clinical record. The NHA was aware the resident had a concern involving an employee and briefly visited the resident, but there was still no documentation of the grievance, demonstrating a failure to follow the facility’s grievance policy and to ensure the resident’s right to voice and have grievances addressed without reprisal.
Staff failed to follow infection control policies for residents on droplet and enhanced barrier precautions. One aide moved directly between the rooms of three residents on different types of precautions without performing required hand hygiene, despite posted signage instructing staff to clean hands before entering and leaving. The aide entered a room on droplet precautions after leaving a room under enhanced barrier precautions, assisted a roommate not on precautions, and later removed trash from one room and carried it into another while wearing the same gloves, then removed the gloves and left without hand hygiene. Residents involved had conditions including diabetes, HTN, heart failure, CKD, dialysis with a PEG tube, and a Foley catheter.
Two residents with significant medical conditions, including heart failure, hypertension, dementia, and atrial fibrillation, did not consistently receive the total assistance with eating and drinking as outlined in their care plans. Despite interventions to provide feeding assistance and monitor nutritional intake, clinical records showed multiple missed instances of required assistance over a 30-day period.
A resident with a stage 4 pressure ulcer and multiple comorbidities did not consistently receive or have documented wound care treatments as ordered, including wound vac changes and alternative dressings when the wound vac was unavailable or not functioning. Nursing notes indicated missed treatments due to unavailable supplies and absent staff, and the Treatment Administration Record showed gaps in documentation of required care.
A resident with anxiety and depression diagnoses received Lorazepam daily for several days after the physician's order had been discontinued. An employee continued to sign out and administer the medication without a valid order, and the administration was not documented under the PRN order, resulting in a failure to follow professional standards for medication administration and documentation.
A resident with muscle wasting, dysphagia, and depression experienced significant unplanned weight loss after staff failed to obtain and document weekly weights as ordered. The weight loss was not promptly identified or addressed, and the care plan was not updated to include nutrition interventions, contrary to facility policy and physician orders.
A resident with a PICC line for IV medications did not have several physician-ordered IV flushes documented in the MAR. Although RNs performed the flushes, they failed to sign off on the MAR, resulting in incomplete clinical records for the resident's care.
A resident with dementia and other conditions was left sitting in a dining area with a urine puddle beneath his chair, compromising his dignity. Despite being informed, a nurse aide delayed providing incontinence care due to being sidetracked, and the issue was only addressed after a surveyor's inquiry.
A resident with urinary incontinence was not provided timely incontinence care as per their care plan. Despite being observed with a urine puddle under their chair, the resident remained in the dining area for over an hour before being taken for care. The DON confirmed the delay was due to a nurse aide being sidetracked with other tasks.
The facility failed to ensure accurate resident assessments, leading to discrepancies in clinical records for four residents. Errors included incorrect MDS coding for falls, dialysis treatment, pressure ulcers, and antipsychotic medication management, as confirmed by staff interviews and documentation reviews.
The facility failed to review and revise care plans for four residents and did not involve four other residents in care plan development. A resident's care plan lacked anticoagulation therapy details, another's was not updated to reflect DNR status, and a third's omitted a cardiac pacemaker. Additionally, a resident's care plan still referenced a removed urinary catheter. The absence of a social worker led to missed care plan meetings for four residents.
The facility failed to document the administration of Levothyroxine for several residents, as required by professional standards. Additionally, a physician's order for extra fluids was not discontinued due to the absence of a stop date. These issues highlight deficiencies in medication administration documentation and order management.
A facility failed to administer the correct dosage of medication to a resident and did not ensure physician's orders were implemented for three residents. One resident received a full 5 mg tablet of oxycodone instead of the prescribed 0.5 tablet on multiple occasions. Additionally, three residents did not receive their 6:00 AM medications, including Buspar, Tylenol, Lasix, and phenobarbital. The DON was informed, and an investigation revealed that the responsible employee did not sign off on the medications, mistakenly believing she could do so remotely.
A facility failed to maintain complete dialysis communication records for a resident with ESRD, missing several communication sheets and post-dialysis weights over multiple months. The DON confirmed the absence of these records and acknowledged ongoing issues with dialysis communication.
The facility failed to maintain accurate records of controlled drug disposition for three residents, leading to missing documentation for medications upon discharge. The DON confirmed the absence of required records, including for a resident with a morphine sulfate order, leaving the disposition of the medication unknown.
A resident with a Stage IV pressure ulcer did not receive prescribed wound care, as staff failed to follow physician orders and facility protocols. The resident's treatment involved specific wound care steps, including the use of silver-infused Aquacel Ag rope and a sacral border dressing, which were not adhered to. Additionally, the wound packing material was handled with ungloved hands, and treatment records lacked documentation for certain dates. The DON confirmed these deficiencies during interviews.
A resident with CHF, chronic kidney disease, and hypertension was not properly monitored for fluid intake, leading to excess fluid consumption beyond physician orders. Observations and interviews revealed that the resident received more fluids than allowed, and staff were not adequately informed about the fluid restriction. Documentation errors further contributed to the deficiency.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and ensure ordered medications were available and administered as prescribed for multiple residents, contrary to facility policy requiring medications to be given in accordance with prescriber orders and within one hour of the prescribed time. For one resident with hypothyroidism and depression, physician orders included nightly doses of Zyprexa and Mirtazapine starting in early January, but the medication administration record (MAR) showed blank entries for two nights and a held dose on the third night, with nursing notes indicating the medications were still waiting to be delivered by the pharmacy after admission from the hospital. Another resident with hypertension, COPD, and a right above-the-knee amputation had an order for IV Meropenem every six hours for a wound, but the MAR documented a scheduled dose as not administered, with nursing notes stating the medication was not yet available from the pharmacy. A resident with bipolar disorder and diabetes had new orders for Lithium and Tizanidine; the MAR showed a bedtime Tizanidine dose not administered and a morning Lithium dose held, with progress notes documenting that the resident was a new admission and staff were waiting for the pharmacy to deliver the Tizanidine, and that the medical director was aware the Lithium was not given. A resident with hypertension and diabetes had multiple antidiabetic and mood-stabilizing medications ordered, including Glipizide, Dapagliflozin, Metformin, and Divalproex. The MAR documented several doses on the first days after admission as held or not administered, with nursing notes indicating the medications were on order or awaiting pharmacy delivery. Another resident with dementia and glaucoma had an ordered ophthalmic solution for glaucoma, but a scheduled dose was documented as not administered due to the medication being unavailable and on order. A resident with COPD and hypertension had an ordered Budesonide-Formoterol inhaler, but the first scheduled evening dose after admission was held, with nursing notes stating the medication was waiting for pharmacy delivery. In interviews, the Nursing Home Administrator initially stated that the facility’s Pyxis was well stocked and that residents would not be admitted without medications available, but later stated she would not necessarily expect medications to be available as ordered all the time and would inform the provider if a medication was not available.
Failure to Honor Resident Grievance Rights and Document Complaint
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to voice a grievance and the failure to promptly investigate and document that grievance. Facility policy stated that any resident or representative may file a grievance orally or in writing, including anonymously, and that the grievance officer and staff would take immediate action to prevent further potential violations of resident rights while an alleged violation was being investigated. A resident who is continent and normally independent in using the restroom during the day reported that on the morning of January 8, 2026, an LPN entered her room to pass medications. When the resident stated she needed to use the restroom and her roommate requested a bedpan, the LPN instead obtained a bedpan, rolled the resident onto it, placed it under her, and left the room. The resident reported being left on the bedpan with the call bell on until she became tired and removed it herself. The resident stated she reported this incident the same day to the Admissions Director and the Social Worker and requested to speak with the Nursing Home Administrator (NHA). The Admissions Director reported that the resident told her she had been put on a bedpan and left there and that she wanted to speak with the NHA, but there was no documentation of this conversation or of notifying the NHA. The Social Worker also reported that the resident described the incident involving the LPN giving the bedpan to the resident instead of the roommate and then leaving, but the Social Worker had no documentation and could not recall if a grievance was filed. Review of the grievance log from November 2025 to the present showed no grievance related to this incident, and there was no documentation in the resident’s clinical record or facility records regarding the concern. The NHA acknowledged being made aware that the resident had a concern with an employee and briefly visited the resident, but had no documentation of the concern at that time. These omissions demonstrate that the facility did not follow its grievance policy or ensure the resident’s right to voice a grievance and have it addressed.
Failure to Follow Hand Hygiene and Transmission-Based Precaution Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control policies, specifically related to hand hygiene and transmission-based precautions for residents on droplet and enhanced barrier precautions. The facility’s policy required that when a resident is placed on transmission-based precautions, appropriate signage be placed on the room entrance door to inform staff of the type of CDC precaution and instructions for PPE and hand hygiene. Resident 1 had a progress note indicating they were to be on contact precautions pending respiratory viral panel results, and a droplet precaution sign was posted on the room door instructing staff to clean their hands before entering and leaving the room. Residents 2 and 3 had physician orders and care plans for enhanced barrier precautions related to dialysis with a PEG tube and a Foley catheter, respectively, with signage on their shared room door requiring hand hygiene before entering and leaving. On one observation date, a nurse aide (Employee 3) was seen leaving the room of Residents 2 and 3, who were on enhanced barrier precautions, and entering Resident 1’s room, which was on droplet precautions, without performing hand hygiene between rooms, despite posted instructions. In Resident 1’s room, Employee 3 assisted the roommate, who was not on precautions, in the bathroom. On a subsequent observation, Employee 3 again entered Resident 1’s room without hand hygiene, donned gloves, removed the trash from that room, then entered the room of Residents 2 and 3 without changing gloves or performing hand hygiene, carrying the trash bag from Resident 1’s room into Residents 2 and 3’s room. Employee 3 then removed gloves and left without performing hand hygiene. During an interview, the Nursing Home Administrator stated she would have expected Employee 3 to perform appropriate hand hygiene before entering and leaving the residents’ rooms.
Failure to Provide Required Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living, specifically eating and drinking, for two residents who were dependent on staff for these tasks. Clinical record reviews showed that both residents had care plans indicating a need for total assistance with eating and drinking, as well as interventions to provide feeding assistance at meals. Despite these documented needs, records revealed multiple instances over a 30-day period where the residents did not receive the required assistance with eating during several meals. One resident had diagnoses including heart failure and hypertension, while the other had dementia and atrial fibrillation, with an identified risk for malnutrition. The care plans for both residents included specific interventions to monitor and assist with nutrition and meal intake. Staff interviews confirmed that documentation of feeding assistance was expected for every meal, yet the records indicated that this assistance was not consistently provided as required.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with heart failure and hypertension, who had a stage 4 pressure ulcer on the sacral region, did not consistently receive necessary wound care treatments as ordered. Clinical record review showed that wound vac changes, wet to dry dressings, and other prescribed treatments were not always documented as completed on the Treatment Administration Record (TAR) for multiple dates. Nursing progress notes indicated that on certain occasions, wound care supplies were unavailable, the wound nurse was not present, and attempts to contact supervisory staff were unsuccessful. There were also instances where the wound vac was not functioning and no alternative dressing was documented as applied, despite orders to do so. Further review of the TAR revealed additional missed or undocumented wound care treatments, including a day when a prescribed wound treatment was left blank, indicating it was not performed. During a staff interview, the Nursing Home Administrator acknowledged the lack of documentation and stated that she expected staff to document all completed treatments. The findings demonstrate that the facility failed to ensure the resident received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer.
Failure to Administer and Document Medication per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety disorder and depression was not provided care in accordance with professional standards. The resident had a physician's order for Lorazepam 0.5 mg daily for anxiety, which was discontinued on May 3, 2025. Despite the discontinuation, Employee 1 continued to sign out and administer the medication for six days after the order had ended, from May 4 to May 9, 2025. During this period, there was no active order for daily Lorazepam, and the administration was not documented under the resident's as-needed (PRN) order for Lorazepam. The medication administration record (MAR) for the resident did not reflect any PRN doses given during the time the daily order was inactive, even though the controlled drug record showed continued administration. This discrepancy was identified after the Director of Nursing was notified and an investigation was conducted. The failure to ensure that medication was administered and documented according to current physician orders and professional standards resulted in the cited deficiency.
Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to properly monitor and document the nutritional status of a resident with diagnoses including muscle wasting, dysphagia, and depression. According to facility policy, residents are to be weighed upon admission and at intervals set by the interdisciplinary team, with any significant weight change requiring confirmation and immediate notification of the dietitian. For this resident, physician orders specified weekly weights for four weeks following admission. However, the clinical record did not show that weights were obtained and documented on two of the required weeks. The resident experienced a significant unplanned weight loss of 7.8% over one month, which was not identified or addressed in a timely manner due to the missed weight checks. Further review revealed that, although the significant weight loss was eventually confirmed, the resident's care plan was not updated to reflect the weight loss or to include nutrition interventions in response. Staff interviews confirmed that the expectation was for weights to be obtained as ordered, reweighs to be performed for confirmation, and care plans to be updated accordingly. The lack of timely monitoring, documentation, and care planning contributed to the failure to maintain the resident's nutritional status within acceptable parameters.
Failure to Document IV Medication Administration in Clinical Record
Penalty
Summary
The facility failed to document physician-ordered medication administrations in the clinical record for one resident. The resident, who had diagnoses including Type 2 Diabetes Mellitus and hypertension, was admitted following hospitalization for sepsis and had a PICC line for intravenous medications. Review of the Medication Administration Record (MAR) showed that several intravenous flushes, specifically Sodium Chloride and Heparin Lock flushes, were not signed off as completed on multiple occasions. Written statements from staff indicated that RNs performed the IV flushes, as LPNs were not permitted to flush PICC lines, but the RNs did not document these administrations in the MAR. The Director of Nursing confirmed that documentation should have been completed for the care and services provided.
Resident Dignity Compromised Due to Delayed Incontinence Care
Penalty
Summary
Capitol Rehabilitation and Healthcare Center was found to be non-compliant with resident rights requirements as outlined in 42 CFR Part 483, Subpart B. The deficiency involved a failure to provide care in a manner that enhanced the dignity of a resident diagnosed with benign prostatic hyperplasia, dementia, and anxiety disorder. On December 23, 2024, the resident was observed sitting in a dining area with a puddle of urine beneath his chair, indicating incontinence. Despite this, the resident was wheeled back to the same spot by a nurse aide, leaving him in an undignified state. Further observations revealed that the resident remained in the dining area without receiving incontinence care until prompted by a surveyor's inquiry. The Director of Nursing confirmed that the resident was incontinent and that a nurse aide had been informed of the need for incontinence care but was sidetracked by other tasks. This delay in providing necessary care until the surveyor's intervention highlighted a lapse in maintaining the resident's dignity and timely care.
Plan Of Correction
1. Resident 1 did not have any adverse reactions. 2. The residents in the North Dining Room will be monitored by the LPN to ensure that the residents are being checked q 2 hours for incontinent care. 3. Nursing staff will be educated on customer service and checking and changing the residents q 2 hours by the DON/Designee on 1/6/2025. 4. DON/Designee will QA weekly for 4 weeks, then monthly to ensure residents are being checked and changed q 2 hours. Results to be reviewed with the QAPI committee. 5. Compliance by 1/21/2025.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide resident-directed care and treatment consistent with the comprehensive plan of care for a resident diagnosed with benign prostatic hyperplasia, dementia, and anxiety disorder. The resident's care plan included an intervention to check the resident approximately every two hours and provide incontinence care as needed. However, documentation revealed that the resident was last assisted with toileting at 9:19 AM, and by 11:47 AM, the resident was observed sitting in a dining area with a puddle of urine underneath his chair. Despite the observation, the resident remained in the dining area until 1:09 PM, when two nurse aides wheeled him into a shower room for incontinence care. The Director of Nursing confirmed that the resident was incontinent and that a nurse aide had been informed of the need for a change but got sidetracked with other tasks. The lack of timely incontinence care was only addressed after the surveyor's inquiry, highlighting a failure to adhere to the resident's care plan and facility policy.
Plan Of Correction
1. Resident 1 did not have any adverse reactions. 2. The residents in North Dining room will be monitored by the LPN's to ensure that the residents are being checked q 2 hours for incontinent care. 3. Nursing staff will be educated on the expectation that residents are checked and changed q 2 hours by the DON/Designee on 1/6/2025. 4. DON/Designee will QA weekly for 4 weeks, then monthly to ensure that residents are checked and changed q 2 hours. Results will be reviewed with QAPI committee. 5. Compliance by 1/21/2025.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to discrepancies in their clinical records. Resident 11's MDS was incorrectly marked for a fall with major injury due to an assumption made by the RNAC based on an x-ray report, despite no documentation of such an injury following a fall. This error was confirmed by both the RNAC and the DON, who acknowledged the mistake in the MDS assessment. Resident 17's admission MDS was inaccurately coded as not receiving dialysis, despite the resident having been on dialysis prior to admission, as confirmed by a hospital discharge summary. This error was identified during an interview with the resident and confirmed by the RNAC, highlighting a failure to accurately reflect the resident's treatment needs in the MDS. Resident 91's MDS assessments inaccurately indicated that a stage 4 pressure ulcer was present upon admission, although it was acquired at the facility. Additionally, Resident 101's MDS assessments failed to document that a gradual dose reduction of antipsychotic medication was clinically contraindicated, despite psychiatric consult notes indicating otherwise. These inaccuracies were confirmed by staff interviews and email communications, underscoring a pattern of errors in resident assessments.
Care Plan Review and Resident Participation Deficiencies
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four residents, and did not provide the opportunity for four other residents to participate in the development, review, and revision of their care plans. Resident 65's care plan did not include information regarding her anticoagulation therapy, despite having a physician's order for Apixaban. The Director of Nursing (DON) acknowledged that the care plan should have included this information. Similarly, Resident 102's care plan was not updated to reflect a change in advanced directives from full code to DNR status, as indicated by the resident's representative. Resident 106's care plan lacked documentation of her cardiac pacemaker, even though there was a physician's order to monitor the pacemaker site. The DON confirmed that the pacemaker should have been included in the care plan. Additionally, Resident 113's care plan still referenced an indwelling urinary catheter, despite the catheter being removed as per physician orders. The DON and Nursing Home Administrator (NHA) admitted that the care plan should have been revised in a timely manner. Furthermore, the facility did not hold care plan meetings for Residents 41, 73, 91, and 101, or involve them or their representatives in the process. The DON explained that the absence of a social worker due to medical leave contributed to the lack of meetings. The DON confirmed that these residents or their representatives should have been invited to participate in care plan meetings, which were not conducted as required.
Medication Administration and Order Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards of practice for several residents. Specifically, for four residents on the East Wing, Levothyroxine, a medication prescribed for hypothyroidism, was not documented as administered by Employee 10 on a specific date. The medication administration records for these residents did not show the required initials indicating that the medication was given, although the Director of Nursing (DON) confirmed that the medications were not present in the residents' compartments, suggesting they were administered. This discrepancy highlights a failure in the documentation process, as medications should be signed off immediately after administration. Additionally, the facility did not discontinue a physician's order for another resident, which involved providing an extra 240 cc of fluids every shift for five days. This order, effective from June, remained active in October because a stop date was not added. The DON acknowledged this oversight during an interview, indicating a lapse in the management of physician orders. These findings demonstrate deficiencies in both medication administration documentation and the management of physician orders, which are critical components of nursing services.
Medication Administration Errors and Omissions
Penalty
Summary
The facility failed to administer the correct dosage of medication for one resident and did not ensure that physician's orders were implemented for three residents. Resident 41, who has diagnoses including dementia and cerebral infarction, was prescribed 0.5 tablet of 5 mg oxycodone for severe pain. However, the resident received the full 5 mg tablet on five occasions, as the medication card contained 5 mg tablets and only one administration was documented as having half a tablet wasted. This error was confirmed by three employees, and although the resident experienced no negative outcomes, the error was reported to the resident's representative and physician. Additionally, the facility failed to administer medications as ordered for three residents on the East Wing. Resident 87, who is cognitively intact, reported not receiving her 6:00 AM medications, including Buspar and Tylenol, which she needs for morning pain. The MAR was not signed off for these medications. Similarly, Resident 69 did not receive her 6:00 AM Lasix for congestive heart failure, and Resident 89 did not receive her 6:00 AM medications, including Tylenol and phenobarbital. The phenobarbital narcotic count confirmed the dose was not administered. The DON was informed of these medication omissions and began an investigation. Employee 10, responsible for the medication pass, claimed to have administered the medications but did not sign them off, mistakenly believing she could do so remotely. The investigation revealed that the administration of Tylenol could not be confirmed, and four doses of levothyroxine were unaccounted for, indicating they were removed but not documented as administered. The DON confirmed that medications should be administered and documented as prescribed, and staff do not have remote access to records.
Incomplete Dialysis Communication Records for Resident with ESRD
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident with end-stage renal disease (ESRD). The facility's policy, last revised in September 2010, requires that residents with ESRD be cared for according to recognized standards, including proper communication between the facility and the contracted ESRD facility. However, a review of the clinical records for a resident with ESRD revealed missing dialysis communication sheets for several dates spanning from February to September 2024. Additionally, post-dialysis weights were not recorded on two specific dates in August and September 2024. Interviews with the Director of Nursing (DON) confirmed the absence of these records and the failure to document necessary information. The DON acknowledged the issue and mentioned that the facility is working on addressing the problems with dialysis communication. The deficiency was identified as a violation of specific Pennsylvania codes related to medical records and nursing services.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to establish a comprehensive system for recording the receipt and disposition of controlled drugs, which led to an inability to accurately reconcile these medications for three residents. The facility's policy on discarding and destroying medications requires detailed documentation, including the resident's name, medication details, and signatures of witnesses, to be maintained for at least two years. However, upon review, it was found that the medication disposition records were missing for Residents 63, 117, and 119, who had been discharged from the facility. This lack of documentation was confirmed through email correspondence with the Director of Nursing (DON), who acknowledged the absence of these records. Resident 63, diagnosed with muscle weakness and hypertension, was discharged without a medication disposition record. Similarly, Resident 117, with diagnoses of muscle wasting and pulmonary embolism, also lacked documentation of medication reconciliation upon discharge. Resident 119, who had COPD and acute respiratory failure, had a physician's order for morphine sulfate, but the disposition record for this controlled drug was missing following the resident's death. The DON confirmed that the medication disposition sheets for Resident 119's morphine sulfate were not in the chart and could not be located, leaving the disposition of the remaining medication unknown.
Failure to Follow Wound Care Protocols for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a Stage IV pressure ulcer, as per professional standards of practice. The resident, who had a history of stroke and a severe pressure ulcer on the left buttock, was prescribed a specific wound care regimen by their physician. This included cleansing the wound with Vashe, applying a triple mix ointment, and using Aquacel Ag rope with a sacral border dressing. However, during an observation, Employee 4 was seen touching the wound packing material with ungloved hands, contrary to the facility's policy and professional standards. Additionally, the employee did not use the prescribed silver-infused Aquacel Ag rope, instead using a non-silver variant, and failed to apply the sacral-shaped mepilex border dressing as ordered. Further review of the resident's treatment records revealed that the prescribed wound care was not documented as completed on two occasions in September. Interviews with the Director of Nursing (DON) and other staff confirmed these lapses in following physician orders and maintaining proper wound care protocols. The DON acknowledged that the treatments should have been provided as ordered and that the employee should not have handled the wound packing material without gloves. Despite these acknowledgments, no additional information was provided to explain why the dressing changes were not completed as ordered on the specified dates.
Failure to Monitor and Manage Fluid Restriction
Penalty
Summary
The facility failed to effectively monitor and manage the hydration status of a resident with a fluid restriction order due to congestive heart failure, chronic kidney disease, and hypertension. The facility's policy on fluid management was not adhered to, as evidenced by multiple instances where the resident received more fluids than prescribed. Observations revealed that the resident was provided with excess fluids during meals and from nursing, exceeding the allowed amounts specified in the physician's orders. The resident was unaware of being on a fluid restriction, indicating a lack of communication and proper management of the care plan. Interviews with staff, including a Licensed Practical Nurse and the Regional Director of Dining, confirmed the oversight in managing the resident's fluid intake. The nurse attributed the excess fluid provision to nurse aide students who were not informed of the fluid restriction. The Regional Director of Dining acknowledged discrepancies in meal tray tickets and additional fluid sources like soup and ice cream that were not accounted for in the fluid restriction. Documentation errors were also noted in the Medication Administration Record, where excess fluid consumption was recorded on several shifts. The facility's management, including the Nursing Home Administrator and Director of Nursing, were made aware of these issues during the survey.
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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