Carbondale Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carbondale, Pennsylvania.
- Location
- 10 Hart Place, Carbondale, Pennsylvania 18407
- CMS Provider Number
- 395260
- Inspections on file
- 18
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Carbondale Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognition and Medicaid coverage was overcharged for care costs due to billing errors, resulting in a $100 discrepancy in personal funds management. The facility failed to properly apply the Personal Needs Allowance when deducting care costs, leading to inaccurate accounting of the resident's finances.
A resident with severe cognitive impairment and high risk for pressure ulcers was not consistently provided with required heel-lift boots as ordered, despite a care plan and physician orders specifying their use. Observations showed the resident without the boots on multiple occasions, with staff confirming the resident often removed them and was instead given slippers. There was no documentation of refusals or interventions to address this, and staff records inaccurately reflected that the boots were in use. The DON confirmed the facility did not consistently follow planned interventions to promote healing or prevent worsening of a pressure ulcer.
A resident with decreased mobility and a history of lung cancer did not receive restorative ambulation services as planned after discharge from PT, despite care plan interventions and documentation indicating otherwise. Both the resident and a nurse aide confirmed that the ambulation program was not implemented, and the DON acknowledged the failure to provide and accurately document the required restorative nursing services.
Surveyors observed unsanitary conditions in the kitchen and resident pantries, including a build-up of black substances under the dishwasher and on ice machine hoses, as well as undated and unmarked resident food items in a refrigerator. Staff confirmed that food items should be dated and that cleaning of equipment was not performed frequently enough to prevent contamination.
A resident developed a blister on the heel, which the facility failed to investigate or communicate about with the family. Initial assessments showed no skin issues, but later documentation noted the blister. The care plan included interventions for skin integrity, but documentation was incomplete. A physician's evaluation identified the blister as a venous wound without supporting evidence. The family filed a grievance, but there was no resolution or discussion about the blister.
A resident experienced significant weight loss over one week, dropping 8.1 pounds despite consuming 70% to 100% of meals. The facility failed to conduct reweights or notify the physician promptly. The RD reviewed the weight loss six days later, but no additional interventions were documented. The DON confirmed the facility's lack of timely response, indicating a deficiency in nursing services.
The facility did not implement proper screening procedures for five employees, including a RN, LPN, and unit aides, as required by their abuse prohibition policy. The policy lacked procedures for obtaining references from previous employers, and there was no evidence that the facility contacted former employers for information. The NHA confirmed this oversight.
A resident with Parkinson's disease and dementia was prescribed Haldol for anxiety and terminal agitation without documented clinical necessity. Despite experiencing falls and dosage increases, there was no physician or hospice documentation justifying the medication's use. The pharmacist's request for a gradual dose reduction was met with insufficient documentation from the physician.
A resident with Parkinson's disease and dementia experienced multiple falls from a wheelchair, resulting in injuries, due to the facility's failure to implement an effective QAPI program. Despite interventions like occupational therapy, the falls continued, indicating insufficient strategies to address the root causes. The facility did not provide additional supervision or conduct thorough investigations, lacking documentation of corrective actions.
A facility failed to conduct a significant change MDS assessment for a resident who was placed on hospice care, as required by federal regulations. The resident experienced a significant decline in condition, but there was no documented evidence of the required assessment. The Nursing Home Administrator confirmed the oversight.
A resident with end-stage renal disease and dependent on dialysis was found without necessary emergency supplies in her room or on her wheelchair, despite her care plan requiring them. Interviews with the resident, an LPN, and the Nursing Home Administrator confirmed the absence of these supplies, indicating a failure by the facility to ensure their availability.
Failure to Accurately Manage and Account for Resident Personal Funds
Penalty
Summary
The facility failed to properly safeguard, manage, and accurately account for the personal funds of a resident who was admitted with a diagnosis of malignant neoplasm of the lung and was cognitively intact, as evidenced by a BIMS score of 15. The resident's payor source was Medicaid, which entitles individuals to a monthly Personal Needs Allowance (PNA). A review of the resident's fund ledger and financial documentation revealed that the facility made incorrect deductions for care costs, resulting in an overcharge. Specifically, the resident was charged a total of $10,025 for care costs from December 2024 through April 2025, when the correct total should have been $9,925 based on the resident's income and the applicable PNA for each month. The discrepancy was identified when the resident noticed a significant charge on his financial statement and brought it to the attention of facility staff. Further review confirmed that the facility was responsible for deducting only the monthly care cost balance after applying the PNA, but billing errors led to an overcharge of $100. The facility's failure to accurately manage the resident's personal funds constituted a violation of the resident's rights and state regulations regarding the management of resident finances.
Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to consistently implement planned interventions to promote healing and prevent the worsening or development of pressure ulcers for one resident. The resident in question was admitted with significant medical conditions, including diabetes and rheumatoid arthritis, and was assessed as being at high risk for pressure sore development due to severe cognitive impairment and dependence on staff for activities of daily living. The care plan and physician orders specified the use of heel-lift boots at all times, except during care, as well as the use of a specialized mattress and pressure redistribution cushion. Despite these documented interventions, multiple observations revealed that the resident was not wearing the required heel-lift boots on two separate occasions. Instead, the resident was found wearing slippers, and the heel-lift boots were observed lying unused in the room. Staff interviews confirmed that the resident often removed the boots, and staff would then put slippers on instead. However, there was no documentation in the care plan or task reports regarding the resident's refusal to wear the boots or any interventions taken to address these refusals. Additionally, staff documentation inaccurately indicated that the heel-lift boots were on the resident at times when direct observation showed otherwise. The Director of Nursing confirmed that the facility did not consistently implement the planned interventions to promote healing or prevent the progression of the resident's right heel pressure ulcer. This failure was found to be noncompliant with facility policy and regulatory requirements.
Failure to Provide and Accurately Document Restorative Ambulation Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned for a resident with decreased mobility and fatigue. The resident, who was cognitively intact and had a history of malignant neoplasm of the lung, was discharged from physical therapy with recommendations for a restorative ambulation program. The care plan specified that the resident should ambulate 50 feet with a rollator walker and the assistance of one caregiver, with interventions including proper footwear, instruction on device use, and wheelchair follow-along as recommended by therapy. Despite these documented interventions, the resident reported that after physical therapy services ended, no staff provided restorative ambulation services for over a month. Clinical records indicated that the resident received the intervention on multiple occasions, but during interviews, both the resident and the nurse aide responsible for the documentation confirmed that the ambulation program was not implemented as recorded. The DON acknowledged that the facility did not provide the planned restorative nursing services and that documentation was inaccurate.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in food storage and sanitation practices within the facility. During an initial kitchen tour, there was a heavy build-up of a black substance under the soiled side counter space of the dishwasher and debris under the ceiling light shield in the janitor's closet. The registered dietitian confirmed that the kitchen should be maintained in a clean and sanitary manner. In the Nursing B Hall Pantry, a refrigerator/freezer contained five undated and unmarked containers of resident food, as well as other undated items such as butter, bread, and ice cream. A registered nurse confirmed that staff are expected to date all food items when opened or received by residents or their families. Further observations in the A Hall and B Hall Nursing Unit pantries revealed a build-up of a black substance on the ends of the condensation hoses of the ice machines. The maintenance director confirmed that the ice machines and their condensation hoses were not cleaned and sanitized frequently enough to prevent this build-up. These findings indicate that the facility did not maintain acceptable practices for the storage and service of food, increasing the risk of contamination and microbial growth.
Failure to Investigate and Address Pressure Ulcer
Penalty
Summary
The facility failed to investigate the origin and promote the healing of a pressure sore for a resident, identified as Resident 1. The resident was admitted with diagnoses including weakness, history of falling, lumbar radiculopathy, and dementia. Initial assessments indicated no skin impairment, but later documentation noted a blister on the resident's left heel. Despite the presence of a blister, there was no evidence of an investigation into its development, and the facility did not provide information to the family regarding the cause of the blister. The care plan for the resident was initiated and updated to address the risk of skin integrity impairment, with interventions such as elevating the resident's heels and documenting skin breakdown. However, the facility's skin integrity report lacked complete documentation, including measurements and staging of the blister. A physician's evaluation later identified the blister as a venous wound, but there was no supporting evidence or collaboration with the physician to confirm this diagnosis. The resident's family expressed concerns about the blister and filed a grievance, but there was no resolution or documented discussion about the blister with the family. Interviews with facility staff revealed that the blister was not investigated because it was assumed to be a venous wound, without evidence to support this assumption. The facility's failure to investigate and communicate about the blister led to the deficiency noted in the report.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to consistently monitor and address a resident's weight loss, leading to a deficiency in providing adequate nutritional support. A resident, who was admitted with conditions including lumbar radiculopathy, dementia, and a history of falling, experienced a significant weight loss of 8.1 pounds, or 4.39%, over one week. Despite consuming between 70% to 100% of meals, the resident's weight dropped from 184.6 pounds to 176.5 pounds between August 1 and August 8, 2024. There was no evidence of reweights to confirm the initial weight loss, and no communication or notification was made to the physician regarding this significant change. The Registered Dietitian reviewed the resident's weight on August 14, 2024, six days after the weight loss was identified, and noted the significant weight loss. However, there was no documented evidence that the physician was notified of this change, nor were additional interventions such as reweights conducted. An interview with the Director of Nursing confirmed the facility's inability to demonstrate a timely response to the resident's weight loss, indicating a lapse in nursing services as per 28 Pa Code 211.12 (d)(3)(5).
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement established abuse prohibition procedures for screening prospective employees, as required by regulatory standards. The facility's Resident Abuse policy, last reviewed on January 3, 2023, did not include procedures for obtaining references from current or previous employers. This omission was identified during a review of the facility's abuse prohibition policy, employee personnel files, and staff interviews. The review revealed that five employees, including a Registered Nurse, a unit aide, an LPN, and another unit aide, were hired without the facility contacting their previous employers for references. The employees' applications indicated prior employment, but there was no evidence that the facility obtained information from former employers. The Nursing Home Administrator confirmed that no previous employers were contacted for information regarding the employees' past employment.
Lack of Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the presence of current documented clinical necessity for the continued use of a psychotropic medication prescribed on an as-needed basis for a resident. The resident, who had diagnoses of Parkinson's disease, dementia, and a history of falling, was placed on hospice services for end-stage Parkinson's disease. A physician order was made for Haldol, an antipsychotic medication, to be administered sublingually every six hours for anxiety and terminal agitation. However, there was no corresponding physician or hospice staff documentation to justify the addition of this medication to the resident's regimen. Following the initiation of Haldol, the resident experienced additional falls, leading to an increase in the medication dosage. Despite further falls and dosage increases, there was still no physician documentation addressing the resident's behaviors and the rationale for the Haldol usage. The pharmacist requested a gradual dose reduction due to the lack of documented rationale for the increased dosage, but the physician only noted increased episodes of agitation without further documentation. The interim Director of Nursing confirmed the absence of necessary documentation regarding the initiation and dosage increases of Haldol.
Repeated Falls Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeated falls of a resident, identified as Resident 65, who was admitted with diagnoses including Parkinson's disease and dementia. The resident had a history of falls and was at risk due to cognitive impairment and mobility issues. Despite being on hospice care for end-stage Parkinson's disease, the resident experienced multiple falls from his wheelchair, resulting in injuries such as lacerations, abrasions, a scalp hematoma, and a lumbar fracture. The facility's QAPI plan, which was supposed to involve all staff and stakeholders in improving quality of care, did not effectively address the root causes of these falls. The resident's care plan acknowledged the risk of falls, but the interventions, including occupational therapy for wheelchair seating and propulsion, were insufficient to prevent further incidents. The resident continued to fall even after therapy sessions, indicating a lack of effective strategies to mitigate the risk. During the survey, it was noted that the facility did not provide additional supervision as a fall prevention measure, and there was no evidence of a thorough investigation or analysis of the adverse events. The facility's QAPI system failed to identify and address the underlying causes of the falls, and there was a lack of documentation to support any corrective actions taken. This deficiency highlights the facility's inability to maintain an active and effective QAPI program to ensure the safety and quality of care for its residents.
Failure to Conduct Significant Change MDS Assessment for Hospice Enrollment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a significant decline in condition and was placed on hospice care. According to the RAI User's Manual, a significant change in status MDS assessment is required within 14 days of the determination of a significant change, such as when a resident enrolls in a hospice program. The clinical record review revealed that the resident was placed on hospice care on May 6, 2024, but there was no documented evidence that a significant change MDS was completed to reflect the initiation of hospice services. An interview with the Nursing Home Administrator confirmed that a comprehensive significant change MDS assessment was not completed as required. This oversight was identified during a review of clinical records and staff interviews, indicating a failure to adhere to federally mandated assessment processes.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 52, who was admitted to the facility with end-stage renal disease and dependence on renal dialysis, was found to lack emergency care supplies in her room and on her wheelchair. The resident's care plan, dated October 8, 2021, specified that 4 x 4 gauze pads and cloth tape should be available at her bedside, but observations on July 11, 2024, revealed that these supplies were not present. Interviews conducted with Resident 52 and Employee 6, an LPN, confirmed the absence of the required emergency supplies. The resident stated that she had never seen the supplies in her room, and the LPN verified their absence. The Nursing Home Administrator also confirmed the facility's failure to provide the necessary emergency supplies at the resident's bedside, as required by the care plan.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
