Cedar Haven Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Pennsylvania.
- Location
- 590 South Fifth Avenue, Lebanon, Pennsylvania 17042
- CMS Provider Number
- 395770
- Inspections on file
- 29
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Cedar Haven Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified that the facility did not employ a full-time registered dietitian and also lacked a qualified dietary services manager to oversee food and nutrition services in the dietitian’s absence. During an interview, the Administrator confirmed that no full-time dietitian was onsite and no qualified dietary manager had been designated, resulting in noncompliance with management requirements for staffing the dietary department.
Surveyors found that OTC medications were not stored and labeled according to facility policy and professional standards. In central supply, OTC medications in factory-labeled bottles were kept on open shelves in a keypad-accessed room used by multiple types of staff, and the central supply manager did not know exactly who had the access code. On six nursing units, multiple med carts contained OTC medications poured into open plastic cups with handwritten labels, including vitamins, supplements, analgesics, laxatives, and other OTC drugs. LPNs on these units could not determine doses, manufacture dates, expiration dates, or when original containers were opened, and in some cases could not identify all pills in mixed or unlabeled cups, even though residents had physician orders corresponding to these medications. The DON acknowledged that OTC medications were being stored in this improper manner, and surveyors determined that this failure to properly store and label medications created an Immediate Jeopardy situation under F761-K.
A resident with congestive heart failure and end stage renal disease received new physician orders for Bumex, a chest x-ray, and double-portion protein at meals, but there was no documented evidence that the resident or their responsible party was notified of these changes. The DON confirmed the lack of documentation.
A resident was transferred to the hospital following a change in condition, but neither the resident nor their representative received the required written notification about bed-hold policies, reasons for transfer, or Ombudsman information at the time of transfer.
A resident with Parkinson's disease and dementia experienced a significant change in condition, including unresponsiveness and difficulty swallowing, which was not promptly communicated to the physician or responsible party. The issue was only addressed after the family intervened, leading to the resident's transfer to the hospital.
A nurse aide filmed a video exposing her breasts in a resident room with two residents present, violating the facility's abuse prevention and social media policies. The incident resulted in psychosocial harm to the residents, one of whom was cognitively impaired. Despite prior training, the aide admitted to the misconduct, leading to her termination.
The facility failed to ensure accurate MDS assessments for two residents. One resident with end-stage renal disease requiring hemodialysis did not have this reflected in their MDS. Another resident with a urinary tract infection and bladder cancer requiring nephrostomy care also had an inaccurate MDS. These inaccuracies were confirmed by the RN Assessment Coordinator.
The facility failed to develop comprehensive care plans for four residents, neglecting to address identified needs such as psychotropic drug use, urinary incontinence, and pain management. Despite these issues being noted in the MDS CAA summaries, the care plans lacked necessary interventions, as confirmed by the DON.
A facility failed to follow physician's orders for a resident with hypertension by administering lisinopril without documenting blood pressure assessments. The resident's medication was given 49 times without checking if the systolic blood pressure was below 110 mm Hg, as required. This deficiency was confirmed by the DON.
A resident with hypertension and anxiety was identified as a candidate for a scheduled toileting program, but the facility failed to implement it. Despite being always incontinent of urine and needing staff assistance, the resident's care plan did not specify the type of incontinence or include a toileting program. The Nursing Home Administrator confirmed the absence of documentation for such a program.
The facility was found to have improperly disposed of trash and refuse, with items such as used briefs, gloves, and an opened plastic bag observed on the ground next to the dumpster. This indicates a failure in maintaining proper waste management practices.
Lack of Qualified Dietary Leadership in Absence of Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager when there was no full-time registered dietitian onsite. During an interview on March 31, 2026, at 2:45 p.m., the Administrator confirmed that the facility did not have a full-time dietitian present and also did not employ a qualified dietary manager in the dietitian’s absence. This deficiency was cited under 28 Pa. Code 201.18(b)(3) related to management requirements for employing sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietitian.
Improper Storage and Labeling of OTC Medications in Medication Carts and Central Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were properly labeled and securely stored in accordance with facility policy and accepted professional standards. Facility policies required that all medications in carts, medication rooms, or central supply be locked at all times unless in use or under the direct observation of the medication nurse, and that nursing staff check medication labels and expiration dates prior to administration. Policies also required that opened multi-dose containers be dated when opened and that the label of all medications be checked against the physician’s order before removal from the container. Additionally, the facility’s procedure for unavailable medications required staff to obtain OTC medications from central supply when not available in the cart and to notify nurse management if a system-wide issue was identified. Surveyors found that OTC medications in central supply were stored in closed, factory-labeled bottles on open shelves in a room accessed by a keypad lock. The Central Supply Manager stated that staff had access to the room via a code, but she was not aware of all staff who had the code, and reported that therapists and nurse aides, in addition to nursing staff, had collected materials from central supply after hours. This meant that OTC medications were not stored in locked compartments accessible only to authorized personnel, contrary to the facility’s own policy and accepted standards for medication security. On six of ten nursing units (1C, 1D, 3C, 3D, 3F, and 4F), surveyors observed OTC medications stored in open plastic cups with handwritten labels inside medication carts, rather than in their original, labeled bottles. On unit 1C, one cart contained seven cups labeled with drug names such as an eye supplement, guaifenesin ER 600 mg, melatonin 5 mg, cetirizine 10 mg, iron, B12 100, and Fiber Con, but the LPN could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened. Another cart on the same unit contained cups labeled with ASA EC, Mucinex, Ibuprofen 200 mg, and a cup labeled Senna 8.6 that contained a mixture of red, pink, and brown pills, some of which the LPN could not identify. Residents on this unit had physician orders that correlated with the medications stored in these cups. On unit 1D, a medication cart contained seven cups labeled with various supplements and medications, including Oyster Shell D3, Cranberry 450, Vit D 2000 iu, omep 2D, MVI, cetirizine, and vit D3 2000 iu. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, even though residents on the unit had orders corresponding to these medications. On unit 3C, a cart contained cups labeled Vitamin D3 50,000 iu, Docusate, and Vit C 500 mg, and the LPN again could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened, despite residents having corresponding physician orders. On unit 3D, a medication cart contained cups labeled Senna 8.6 mg, Vitamin D3 50,000, Multivitamin, and Fiber-lax, and the LPN could not determine manufacture dates, expiration dates, or when the original containers had been opened, while residents on the unit had orders matching these medications. On unit 3F, one cart contained cups labeled Vit D 2,000 iu and Tylenol 500, and another cup labeled Iron 325 that contained white and black pills, some of which the LPN could not identify or trace back to an original container. A second cart on 3F contained cups labeled Calcium 600+D 10 mcg and Iron 325, with the LPN again unable to determine manufacture dates, expiration dates, or opening dates of the original containers, even though residents had corresponding orders. On unit 4F, one medication cart contained 14 cups labeled with various medications and supplements, including Docusate Sodium, Ibuprofen, Oyster Calcium, Iron, Multi vitamins, Cranberry, Mag Ox, Aspirin, ASA 81, Docusate, Multivit, Therems, Fe sulp, and Oyster Cple. Another cart on the same unit contained two unlabeled cups with pills and ten cups with handwritten labels such as Vit B12, Cranberry, Ibuprofen, Iron, Aspirin, Multivit, Oyster Cal, Thera-M, VitD, and Certizine. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, and could not identify the pills in the two unlabeled cups, even though residents on the unit had physician orders that correlated with the medications in these cups. The DON confirmed that OTC medications were improperly stored and labeled in open, hand-labeled cups in the medication carts. The surveyors determined that this failure to properly store and label medications put residents at risk for medication administration errors and resulted in an Immediate Jeopardy situation at F761-K.
Removal Plan
- Discard and destroy all medications observed in medication cups or unlabeled cups, or any medication that is unable to be identified.
- Replace any discarded medication with an unopened, labeled OTC medication bottle.
- Store OTC medications in the original, labeled bottle in the medication carts and administer to residents following medication administration policies.
- Submit OTC medication orders with the Clinical Supply order and purchase needed OTC medications from a local pharmacy if not sent, backordered, or out of stock.
- Change the Central Supply keylock code and provide it only to central supply staff and RN Supervisors.
- Train all licensed and central supply staff regarding storage of medications, proper distribution of OTC medications, and the medication not available procedure.
- Audit all medication carts to ensure no loose or unlabeled medications are stored in any cart.
Failure to Notify Resident or Responsible Party of Physician-Ordered Treatment Changes
Penalty
Summary
The facility failed to notify a resident or their responsible party of changes in physician-ordered treatments. Clinical record review showed that the resident, who had diagnoses including congestive heart failure and end stage renal disease, received new physician orders for Bumex (a diuretic) twice daily, a chest x-ray, and double-portion protein at meals over several days. There was no documented evidence that the resident or their responsible party was informed of these changes. The Director of Nursing confirmed during interview that there was no documentation of such notifications.
Failure to Provide Written Notification of Bed Hold and Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative regarding bed-hold policies and the reasons for a facility-initiated transfer to the hospital. Clinical record review showed that after a change in condition, the resident was transferred and admitted to the hospital. However, there was no documentation indicating that the resident's representative received written information about the bed hold or the transfer at the time it occurred. Additionally, required information about Ombudsman services was not provided in writing as mandated by regulations.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, who had diagnoses including Parkinson's disease and dementia, exhibited signs of a change in condition on February 1, 2025. A nurse noted that the resident was not acting like herself, had difficulty grasping a cup, and was unresponsive to questions. Later, the resident was unable to eat supper, chew, or swallow without encouragement, prompting the nurse to order a speech therapy screen. Despite these observations, there was no evidence that the physician or responsible party were notified of the resident's condition change until the following day, February 2, 2025, when the resident's family alerted the nurse to the change in mental status. The nurse then documented that the resident was alert but unresponsive, unable to move her arms or legs, and nonverbal. The physician was finally notified and instructed the staff to send the resident to the hospital for evaluation. The Director of Nursing confirmed that the responsible party and physician should have been notified earlier.
Plan Of Correction
1. Resident 1's provider and family notified. Meeting with RP was held and status updates provided. 2. Reviewed all residents who were transferred to hospital in last 30 days for notification of RP and provider. 3. Re-educate licensed nurses on the importance of promptly notifying the physician and responsible party regarding any significant change in a resident's condition. 4. Perform weekly audits for the next four weeks of residents transferred out of facility with changes in condition to ensure compliance with notification procedures. 5. DON/designee will report audit findings at next 2 QAPIs for review and recommendations.
Mental Abuse Incident Involving Nurse Aide
Penalty
Summary
The facility failed to protect two residents from mental abuse, resulting in psychosocial harm. The incident involved a nurse aide, Employee 1, who filmed a video in a resident room where she exposed her breasts while two residents were present. This act was captured on video and shared via a text message, which was later reported. The facility's policy on abuse prevention and reporting, as well as the use of social media, explicitly prohibits such behavior, indicating a breach of protocol by Employee 1. Resident 65, who had no cognitive impairment, and Resident 227, who was cognitively impaired, were both present during the incident. The facility's documentation confirmed that Employee 1 had received prior training on abuse prevention and the prohibition of using personal devices for non-work-related purposes. Despite this, Employee 1 admitted to filming the video, acknowledging the wrongdoing. The facility substantiated the allegation of mental abuse against the residents, leading to Employee 1's termination.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the current status of two residents. Resident 57, who had end-stage renal disease and required hemodialysis, had a care plan indicating dialysis on specific days. However, the MDS assessment did not reflect that the resident received dialysis. Similarly, Resident 178, diagnosed with a urinary tract infection and bladder cancer, had a care plan that included nephrostomy care. The MDS assessment for this resident also failed to indicate the presence of a nephrostomy. These inaccuracies were confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS assessments for both residents were not accurate.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as identified in their comprehensive assessments. Resident 49, who was admitted with diagnoses including diabetes, kidney disease, and heart failure, had a care plan that did not address psychotropic drug use and urinary incontinence, despite these issues being noted in the Minimum Data Set (MDS) Care Area Assessment (CAA) summary. Similarly, Resident 62, with dementia and hypertension, had no interventions for urinary incontinence included in their care plan, even though it was identified as a need in the MDS CAA summary. Resident 133, diagnosed with hypertension and anxiety, was receiving both an antipsychotic and antidepressant, yet their care plan lacked interventions for psychotropic drug use. Resident 242, with a fractured femur, pain, and dementia, was receiving pain medication, but their care plan did not address pain management. The Director of Nursing confirmed the absence of documented evidence that these care areas were addressed in the care plans, indicating a failure to meet the residents' identified needs.
Failure to Document Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for one of the 36 sampled residents, specifically Resident 224. The policy on Medication Administration, last reviewed in October 2024, required staff to administer medications according to the physician's written orders and to document vital signs in the Medication Administration Record as indicated. Resident 224, who had a diagnosis of hypertension, was prescribed lisinopril to be administered once daily, with the condition that it should not be given if the resident's systolic blood pressure was less than 110 mm Hg. However, a review of the Medication Administration Records for October and November 2024 showed that the medication was administered 49 times without any documentation of blood pressure assessment prior to administration, as required by the physician's order. This was confirmed by the Director of Nursing during an interview on November 21, 2024.
Failure to Implement Scheduled Toileting Program for Resident
Penalty
Summary
The facility failed to assess and provide appropriate services for bladder incontinence for one resident. According to the facility's Bowel and Bladder Management policy, staff were required to complete a urinary incontinence assessment upon admission and whenever there was a change in a resident's urinary tract function. This included reviewing the pre-admission history, assessing the current bladder elimination problem, and identifying causes of incontinence. If a change in incontinence was noted, staff were to implement a toileting diary to determine the resident's voiding pattern and develop a toileting program. The type of urinary incontinence was to be identified in the care plan with specific interventions. For Resident 133, who was admitted with diagnoses including hypertension and anxiety, a Bowel and Bladder Program Screener indicated the resident was a candidate for a scheduled toileting program. However, the Minimum Data Set assessment showed the resident was always incontinent of urine and required staff assistance for toileting, yet was not on a toileting program. The care plan did not identify the type of urinary incontinence, nor was there evidence of a scheduled toileting program being implemented. The Nursing Home Administrator confirmed the lack of documentation for a toileting program for this resident.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed in the trash compactor area. During the inspection, various items were found on the ground next to the dumpster, including two used briefs, four used gloves, and a large opened plastic bag. This observation was made on November 19, 2024, at 10:30 a.m., indicating a lapse in proper waste management practices.
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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