Caring Place, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Pennsylvania.
- Location
- 103 N. Thirteenth Street, Franklin, Pennsylvania 16323
- CMS Provider Number
- 395959
- Inspections on file
- 25
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Caring Place, The during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and homelike environment due to insufficient housekeeping coverage, with schedules showing only one housekeeper assigned to a 100-bed building on multiple days. A resident reported dissatisfaction with housekeeping and pointed out dried salad dressing and coffee on the floor near a roommate’s bed that had been present for some time. Observations revealed a dirty entryway with a tracked white substance, a resident room with dried coffee and a dark stain that appeared to be fecal matter, a soiled privacy curtain, and dirt and debris under stored wheelchairs. Hallways on an upper floor had a thick layer of dirt and evidence of an uncleaned spill, and several rooms contained debris. Only one housekeeper was observed working on both day and evening shifts, and the NHA confirmed the unclean conditions in the entry, hallways, and resident rooms.
Surveyors found expired and unlabeled medications on two medication carts and in a medication room. An LPN confirmed that open bottles of Ibuprofen and liquid protein were not properly dated or discarded, and expired insulin pens and vials were also present. In the medication room refrigerator, expired Amoxicillin and IV antibiotics were found, with staff confirming these should have been discarded. Facility policies requiring monitoring and labeling of medications were not followed.
Three residents with complex medical conditions were transferred to the hospital without being provided written notice of the facility's bed-hold policy, including cost per day, and without necessary clinical information being communicated to the receiving provider. Documentation related to the basis for transfer and required notifications was incomplete, as confirmed by the DON.
Two residents did not receive respiratory care as ordered, including failure to change and date oxygen tubing weekly and not administering oxygen at the prescribed flow rate. LPNs confirmed that oxygen equipment was not dated and that oxygen was delivered at a lower rate than ordered.
A resident with end stage renal disease and other chronic conditions did not receive prescribed doses of Hydralazine and Metformin on multiple dialysis days, as documented in the MARs. The medications were not administered because the resident was out of the facility for dialysis, and there was no evidence that the physician was notified to alter or hold the medication schedule. The DON confirmed the missed doses, resulting in a deficiency for not following physician's orders.
A resident with anxiety and hypothyroidism was observed multiple times in bed without access to a call bell, which was found lying under the bed. An LPN confirmed the call bell was not accessible, despite facility policy requiring residents to have access to a means of calling staff for assistance.
A resident with significant mobility limitations and clear orders for two-person assistance during transfers was transferred by a single nurse aide, contrary to documented care requirements. This action resulted in the resident falling and suffering a fractured femur, necessitating hospital treatment.
Two residents requiring two-person assistance for transfers were improperly transferred by a single staff member, contrary to care plans and therapy recommendations. One resident was lowered to the floor after an unsafe toileting transfer, while another sustained a fractured femur following a solo transfer in the shower room. Staff interviews and documentation confirmed that prescribed transfer protocols were not followed.
A resident with a history of cerebral infarction and muscle weakness suffered a fracture due to neglect in a transfer process. Despite orders for a mechanical lift and two staff assistance, an agency NA independently transferred the resident without mechanical aid, leading to the injury. The facility's investigation confirmed the breach of protocol.
A facility failed to administer medications as ordered for a resident undergoing dialysis. The resident, with multiple diagnoses including end-stage renal disease, missed several doses of prescribed medications on dialysis days. The facility's policy requires medications to be administered as prescribed, but there was no documentation of physician notification for missed doses. The DON confirmed the medications were not given as ordered.
The facility did not provide the required SNF ABN Form CMS-10055 to a resident or their representative when skilled Medicare Part A services were ending. The facility's policy mandates notification and acknowledgment of receipt, but there was no evidence of compliance. This was confirmed by the Nursing Home Administrator.
A facility failed to review and revise a resident's care plans within the required timeframe. The resident, with Alzheimer's, colon cancer, and a fractured hip, had 15 care plans with an outstanding target date. The RN Assessment Coordinator confirmed the care plans were not updated as required.
The facility failed to follow physician's orders for medications and weight monitoring for three residents. A resident did not receive prescribed medications on multiple occasions, while two residents had significant gaps in weight documentation. Additionally, one resident had an inaccurate order for a foley catheter. The DON confirmed these deficiencies.
A facility failed to obtain a physician's order for oxygen therapy for a resident with COPD, multiple sclerosis, and anxiety. The resident was observed using an oxygen nasal cannula connected to an oxygen concentrator without a documented physician's order, as confirmed by an LPN. Facility policy requires a physician's order for oxygen administration, except in urgent situations.
The facility failed to document a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days for a resident and did not attempt non-pharmacological interventions before administering PRN psychotropic medications for two other residents. The Director of Nursing confirmed these deficiencies.
The facility failed to store Schedule II-V medications in a permanently affixed compartment and did not appropriately label or discard outdated insulin pens. Lorazepam was improperly stored in a non-affixed box, and insulin pens lacked open dates, violating facility policy and manufacturer guidelines.
An LPN failed to clean a blood glucose meter after using it on a resident, contrary to the facility's policy and manufacturer's guidelines, which require cleaning between each patient use. This oversight was confirmed during an interview with the LPN, highlighting a deficiency in the facility's infection prevention and control practices.
A facility failed to ensure a physician reviewed a resident's total program of care, including medications, during visits. A resident with multiple health issues did not receive the prescribed medication Eliquis from 2/2/24 through 4/8/24, despite documentation indicating it was necessary. The CRNP did not review current medications or communicate with staff to ensure accuracy, leading to the oversight.
The facility failed to conduct thorough monthly drug regimen reviews, leading to the abrupt discontinuation of Eliquis for a resident with a history of pulmonary emboli and deep vein thrombosis. The pharmacist did not identify or report this irregularity in subsequent reviews, as confirmed by the DON.
Inadequate Housekeeping Staffing Leads to Unsanitary Resident Areas
Penalty
Summary
Surveyors determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment due to inadequate housekeeping staffing and unclean conditions in multiple areas. Facility policy titled "Homelike Environment" dated 5/27/25 stated that residents are to be provided with a safe, clean, and comfortable homelike environment, including a clean, sanitary, and orderly environment. Review of the grievance log showed a grievance dated 11/13/25 reporting that a resident's room was not being cleaned appropriately. Review of housekeeping schedules from 12/28/25 through 1/24/26 revealed several days with only one housekeeper scheduled to cover the entire 100-bed facility, including resident rooms, bathrooms, common areas, hallways, and offices. On observation at approximately 1:30 p.m. on 1/20/26, the entryway was covered in a thick layer of a dry white substance that appeared to be tracked throughout the first floor. During an interview at approximately 2:15 p.m. the same day, a resident reported being very dissatisfied with housekeeping and stated there was dry salad dressing and coffee on the floor next to the roommate's bed that had been there "for a while." Observation of that resident's room revealed a dry coffee stain on the floor, a dry dark stain on the floor that appeared to be fecal matter, a privacy curtain soiled with a brown-colored substance, and dirt, dust, and debris under two wheelchairs stored in the corner. Additional observations on the second floor showed hallways with a thick layer of dirt and a completely dry area where something had been spilled, as well as debris in several resident rooms. Only one housekeeper was observed cleaning on day shift and one on evening shift. During a tour and interview at approximately 3:35 p.m. on 1/20/26, the Nursing Home Administrator confirmed the dirty conditions in the first-floor entry, hallways, and resident rooms on the second floor.
Expired and Unlabeled Medications Found in Medication Carts and Room
Penalty
Summary
Surveyors identified that the facility failed to appropriately discard outdated medications and did not ensure proper labeling of opened medications on two of four medication carts and in one of two medication rooms. Observations revealed an open bottle of Ibuprofen with an expiration date of 5/2025 and an open bottle of liquid protein without an open date on the first floor C-wing medication cart. Staff confirmed that the Ibuprofen was expired and the liquid protein lacked an open date, making it impossible to determine the discard date. Additionally, on the second floor C-wing medication cart, an open insulin pen of Lispro and an open vial of Lantus insulin were found to be beyond their use-by dates, as confirmed by staff. Further inspection of the second-floor medication room refrigerator revealed an open bottle of liquid Amoxicillin, four IV bags of Ceftriaxone, and three IV bags of Cefazolin, all of which were past their expiration dates. Staff interviews at the time of observation confirmed that these medications should have been discarded. The facility's policies required monitoring of medication expiration dates and proper labeling of multi-dose containers with the date opened, but these procedures were not followed, resulting in the presence of expired and improperly labeled medications in storage areas.
Failure to Provide Bed-Hold Policy Notification and Complete Transfer Documentation
Penalty
Summary
The facility failed to provide required written notice of its bed-hold policy, including the duration a bed can be held during a leave of absence and the associated cost per day, to residents and/or their representatives at the time of transfer. This deficiency was identified through review of facility policies, clinical records, and staff interviews, which revealed that three residents were transferred to the hospital without documentation that the bed-hold policy was communicated to them or their representatives. Additionally, the clinical records for these residents did not contain evidence that necessary clinical information was communicated to the receiving health care provider upon transfer. Specifically, one resident with chronic obstructive pulmonary disease, Parkinson’s disease, and hypertension was transferred to the hospital without documentation of the required notifications or communication of clinical information. Another resident with atrial fibrillation, heart failure, anxiety disorder, and hypertension experienced multiple hospital transfers, with records lacking both the bed-hold policy notification and complete documentation regarding the basis for transfer, interventions, and appropriate contacts. A third resident with heart disease, atrial fibrillation, heart failure, hypertension, and anxiety was also transferred without evidence of bed-hold policy notification. The DON confirmed these deficiencies during an interview.
Failure to Provide Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders and facility policy for two residents requiring oxygen therapy. For one resident with chronic respiratory failure and muscle weakness, the physician's order specified that oxygen tubing should be changed and dated weekly on the night shift every Thursday. However, observation revealed that the nasal cannula was not dated, and the humidifier solution cannister attached to the oxygen concentrator was last dated nearly two weeks prior. An LPN confirmed these findings during the observation. For another resident with chronic obstructive pulmonary disease, asthma, and hypertension, the physician's order required oxygen to be administered at three liters per minute via nasal cannula to maintain oxygen saturation above 90%. Multiple observations showed the resident receiving supplemental oxygen at only two liters per minute, which was not in accordance with the physician's order. An LPN confirmed that the oxygen flow rate was set incorrectly. These failures were identified through review of clinical records, direct observation, and staff interviews.
Failure to Administer Dialysis Resident's Medications as Ordered
Penalty
Summary
The facility failed to administer medications according to physician's orders for a resident receiving dialysis. Facility policy requires that medications be administered safely, timely, and as prescribed, including adherence to any required time frames. For a resident with diagnoses including hypertension, muscle weakness, type II diabetes, and end stage renal disease requiring regular dialysis, physician's orders specified Hydralazine 25 mg three times daily and Metformin 500 mg twice daily. Review of the Medication Administration Records for June and July showed that the resident did not receive the noon doses of Hydralazine and Metformin on multiple dates corresponding to dialysis days, with the reason documented as 'Not in Facility.' There was no documentation that the physician was notified regarding the need to hold or alter the administration times for these medications on dialysis days. During an interview, the Director of Nursing confirmed that the medications were not administered as ordered on those days. This failure to follow physician's orders and facility policy resulted in a deficiency under the cited nursing services regulation.
Call Bell Inaccessibility in Resident's Room
Penalty
Summary
The facility failed to ensure that a call bell was accessible to a resident, as required by facility policy. Observations on multiple occasions showed that the resident, who had a history of anxiety and hypothyroidism and was admitted on 9/10/24, was in bed with the call bell lying under the bed and not within reach. This was confirmed by an LPN during an interview, who acknowledged that the call bell was not accessible and that the resident should always have access to it. The deficiency was identified through review of facility policy, clinical records, direct observation, and staff interview.
Resident Sustains Fractured Femur Due to Improper Solo Transfer
Penalty
Summary
A facility failed to protect a resident from neglect, resulting in actual harm. The resident, who had a history of stroke, Parkinson's Disease, and muscle weakness, was assessed as requiring extensive assistance from two staff members for all transfers, as documented in the physician's orders, MDS assessment, and occupational therapy notes. Despite these clear instructions, a nurse aide knowingly transferred the resident alone, without the required second staff member, during a shower transfer. This improper transfer led to the resident falling and sustaining a fractured left femur, which required hospital admission for treatment. The incident was confirmed through facility documentation, staff interviews, and an internal investigation, which established that the nurse aide was aware of the resident's transfer requirements but chose to act alone, directly resulting in the resident's injury.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that residents were transferred according to their care plans and therapy recommendations, resulting in unsafe transfers for two residents. One resident, admitted with respiratory failure, muscle weakness, and abnormal gait, required the assistance of two staff for transfers and was not yet assessed for safe toileting transfers. Despite this, a nurse aide attempted to transfer the resident to the toilet alone, causing the resident's knees to buckle and requiring the resident to be lowered to the floor. Occupational therapy confirmed that the resident should have been provided a bed pan until a safe transfer status was established. Another resident, with a history of stroke, Parkinson's Disease, and muscle weakness, also required extensive assistance of two staff for transfers, as documented in the care plan and therapy notes. However, a nurse aide transferred this resident alone in the shower room, contrary to the care plan and physician's orders. This improper transfer resulted in the resident falling and sustaining a fractured left femur, requiring hospital admission for treatment. Interviews with facility staff and review of documentation confirmed that in both cases, staff knowingly failed to follow the prescribed transfer protocols, acting independently rather than with the required assistance. There was also confirmation that the facility did not have a specific policy regarding adherence to therapy transfer orders, relying instead on staff to refer to the electronic care plan.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The deficiency involved a resident with a history of cerebral infarction, muscle weakness, and major depressive disorder, who had a physician's order for transfers using a mechanical lift with the assistance of two staff members. Despite this, an agency nursing assistant independently transferred the resident without mechanical assistance, leading to a fracture of the right humeral head of the right shoulder. The incident occurred when the agency nursing assistant was asked to assist another nursing assistant with the transfer. However, upon arrival, the second nursing assistant found that the agency nursing assistant had already transferred the resident to bed without using the mechanical lift. This improper transfer was contrary to the resident's care plan and physician's orders, which specified the use of a mechanical lift and two staff members for transfers. The facility's investigation revealed that the agency nursing assistant had signed the facility's orientation policy, which included ensuring staff knew where to locate transfer status for safe resident transfers. Despite this, the agency nursing assistant did not adhere to the required procedures, resulting in the resident's injury. The facility confirmed the deficiency during an interview with the Nursing Home Administrator and Director of Nursing.
Removal Plan
- Immediate Suspension and Do Not Return of agency NA Employee E1.
- Immediate education regarding checking transfer status before ambulating or transferring a resident was provided to nursing staff which included RN's, LPN's, and NA's.
- Review of all resident transfer status completed by the Assistant Director of Nursing RN Employee E12 in conjunction with the Therapy Department.
- All staff included in the education also completed competencies conducted by the Management Team.
- Audits were conducted to ensure residents are transferred per their care plans and physician orders with all transfers performed appropriately.
Failure to Administer Medications as Ordered for Dialysis Resident
Penalty
Summary
The facility failed to administer medications according to physician's orders for a resident receiving dialysis. The facility's policy on administering medications requires that they be given in a safe and timely manner as prescribed, and any concerns should be communicated to the prescriber. However, for Resident R66, who has diagnoses including heart failure, atrial fibrillation, diabetes with diabetic neuropathy, and end-stage renal disease requiring dialysis, medications were not administered as ordered on several occasions. Specifically, the resident missed doses of Bacitracin-Polymyxin B ophthalmic ointment, Gabapentin, Lanthanum Carbonate, Midodrine, and Zofran on various dates when the resident was away for dialysis. The Medication Administration Records for July and August 2024 showed that the resident did not receive the noon doses of these medications on multiple days, with the reason noted as "Not in Facility." There was no documentation indicating that the physician was notified about the need to hold or adjust the timing of these medications on dialysis days. The Director of Nursing confirmed that the medications were not administered as ordered on those days, which constitutes a failure to follow the facility's medication administration policy.
Failure to Provide SNF ABN Form to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form CMS-10055 to a resident, identified as Resident R43, or their representative. According to the facility's policy dated February 5, 2024, the facility is obligated to notify Medicare beneficiaries when their skilled Medicare Part A services are ending, using the SNF ABN form. The policy also requires that the resident or their representative sign the notice to acknowledge receipt, or if unavailable, a certified return receipt letter should be sent. However, the Beneficiary Protection Notification Review indicated that Resident R43 began receiving skilled services on March 18, 2024, and the last covered day was March 21, 2024, but there was no evidence that the SNF ABN form was provided. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the oversight.
Failure to Review and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and/or revise the care plans for a resident, identified as R38, within the required timeframe. According to the facility's policy, a comprehensive care plan should be developed within seven days of completing the resident assessment (MDS). Resident R38, who was admitted with diagnoses including Alzheimer's, colon cancer, and a fractured left hip, had 15 care plans with an outstanding target date of 6/21/2024. These care plans covered various problem categories such as impaired skin integrity, activities, constipation, musculoskeletal issues, and more. During an interview, the Registered Nurse Assessment Coordinator confirmed that the care plans for Resident R38 were not reviewed or revised as required.
Failure to Follow Physician's Orders for Medications and Weight Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were followed for three residents, leading to deficiencies in medication administration and weight monitoring. Resident R66, who had multiple diagnoses including heart failure and end-stage renal disease, did not receive or refuse prescribed medications Zofran and Protonix on several occasions in July 2024, as documented in the medication administration record. The Director of Nursing confirmed the lack of documentation for these medications. Resident R28, diagnosed with congestive heart failure and respiratory failure, had a physician's order for weekly weights and a foley catheter, but there was no documented evidence of a weight being taken for 11 days, and observations confirmed the absence of a foley catheter. Similarly, Resident R67, with diagnoses including diabetes and dementia, had a physician's order for weekly weights, but there were significant gaps in weight documentation, with periods of 13, 19, and 21 days without recorded weights. The Director of Nursing confirmed the lack of documentation for weights and the inaccuracy of the foley catheter order for Resident R28.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the provision of oxygen therapy for a resident, identified as R293, who was reviewed for respiratory services. The facility's policy, dated February 5, 2024, states that oxygen is considered a drug and can only be administered with a physician's order, except in urgent or emergent situations where a licensed nurse may initiate it. However, the physician must be notified for appropriate orders. Resident R293, who has diagnoses including chronic obstructive pulmonary disease (COPD), multiple sclerosis, and anxiety, was observed on two occasions wearing an oxygen nasal cannula connected to an oxygen concentrator delivering 2 liters per minute. The resident's clinical record lacked evidence of a physician's order for the use of oxygen therapy. This was confirmed during an interview with an LPN, who acknowledged the absence of a physician's order in the clinical record.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication beyond 14 days for one resident and did not attempt non-pharmacological interventions prior to administering PRN psychotropic medications for three residents. Specifically, Resident R10 was prescribed Ativan for anxiety without a required stop date or clinical rationale for its continued use beyond 14 days. The medication was administered multiple times without evidence of non-pharmacological interventions being attempted prior to its use. Additionally, Resident R38 was prescribed Lorazepam for anxiety and agitation, and it was administered several times without documentation of non-pharmacological interventions being attempted beforehand. Similarly, Resident R293 received Lorazepam for anxiety, and non-pharmacological interventions were not documented prior to its administration on multiple occasions. The Director of Nursing confirmed these deficiencies during an interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper storage and labeling protocols for medications, specifically Schedule II-V drugs and insulin pens. During a review of the facility's policies and procedures, it was noted that the facility's policy required all drugs, including Schedule II-V medications, to be stored in separately locked, permanently affixed compartments. However, an observation of the First Floor medication room revealed that Lorazepam, a controlled antianxiety medication, was stored in a clear plastic box on a shelf that was not permanently affixed to the refrigerator, allowing for easy removal. This was confirmed by a Registered Nurse, who acknowledged that the storage did not comply with the facility's policy. Additionally, the facility failed to appropriately discard outdated medications. During an inspection of the C wing medication cart, it was found that open pens of Lantus and Humalog Insulin lacked dates indicating when they were opened. According to the manufacturer's guidelines, these insulin pens should be used within 28 days of opening or be discarded. A Licensed Practical Nurse confirmed that the insulin pens had no open dates and should have been discarded, as per the guidelines. This oversight in labeling and discarding outdated medications represents a failure to comply with the facility's own policies and the manufacturer's guidelines.
Failure to Clean Blood Glucose Meter
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not properly cleaning a blood glucose meter (BGM) after use, which could lead to cross-contamination. The facility's policy, dated February 5, 2024, and the manufacturer's guidelines for the Evencare Proview meter both require that the BGM be cleaned and disinfected between each patient use. However, during an observation on August 6, 2024, it was noted that an LPN did not clean the BGM after using it on a resident. Instead, the LPN placed the BGM back into the medication cart without cleaning it, contrary to the facility's policy and the manufacturer's instructions. During an interview conducted at the time of the observation, the LPN confirmed that the BGM was not cleaned before being returned to the medication cart. The LPN acknowledged that the BGM should be cleaned after every resident use and before being placed back into the cart. This incident involved one of seven residents observed during the administration of medications, specifically Resident R75. The failure to clean the BGM as required by both the facility's policy and the manufacturer's guidelines constitutes a deficiency in the facility's infection prevention and control practices.
Failure to Review Resident's Total Program of Care
Penalty
Summary
The facility failed to ensure that the physician reviewed the resident's total program of care, including medications, during physician visits for one resident. The facility's policy required oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing to ensure the resident's highest practicable level of well-being. However, the clinical record of a resident with multiple subsegmental pulmonary emboli, muscle weakness, and hypertension revealed that the resident was not receiving the prescribed medication Eliquis from 2/2/24 through 4/8/24, despite the CRNP documenting that the resident was to remain on the medication long-term. The CRNP's progress notes during visits on 2/1/24, 2/16/24, and 3/1/24 indicated that the resident was receiving Eliquis, although it had been discontinued after the 2/1/24 doses. The Director of Nursing confirmed that the CRNP did not review the resident's current medications during visits or communicate with nursing staff and the pharmacy to ensure the accuracy of the resident's total program of care. This oversight led to the resident not receiving the necessary anticoagulant medication for an extended period.
Failure to Conduct Thorough Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to properly conduct thorough monthly drug regimen reviews for one resident, leading to a deficiency in identifying, reporting, and resolving medication-related problems. The licensed pharmacist did not document irregularities regarding the medication Eliquis, which was prescribed for a resident with a history of pulmonary emboli and deep vein thrombosis. Despite the resident's need for long-term anticoagulant therapy, the medication was abruptly discontinued after the last dose was administered on 2/1/24, and this discontinuation was not identified in subsequent monthly reviews on 2/5/24 and 3/19/24. The resident's clinical records and progress notes indicated that the resident was to remain on Eliquis long-term, yet the medication was not administered or ordered in March 2024. The Director of Nursing confirmed that the pharmacist did not conduct a thorough review, failing to prevent, identify, report, and resolve the medication irregularities. This deficiency was identified during a survey, and it was determined that the facility did not comply with the required pharmacy and nursing services regulations.
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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