Cedarwood Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tyrone, Pennsylvania.
- Location
- 951 Washington Avenue, Tyrone, Pennsylvania 16686
- CMS Provider Number
- 395393
- Inspections on file
- 52
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Cedarwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and mobility limitations sustained an unwitnessed fall in a hallway, reported hitting the head, and later was found to have a left proximal humerus fracture. Dietary staff discovered the resident on the floor, were unable to locate a nurse, and lifted the resident into a rolling desk chair before nursing staff assessed the resident, while CNAs and an RN later confirmed hearing that dietary staff had assisted the resident from the floor. Although dietary aides reported completing witness statements, the facility’s investigation included only statements from a CNA and an LPN who was on break at the time, and omitted the dietary staff accounts and any examination of the lack of RN assessment prior to moving the resident, contrary to facility policy requiring prompt, comprehensive incident investigations.
A resident with a stage 4 right hip pressure ulcer had physician orders for wound vac therapy at 120 mmHg suction, with specific cleaning and dressing change instructions. A wound consultant later recommended increasing the wound vac suction to 150 mmHg, but this change was never incorporated into the physician’s orders or the Treatment Administration Record. As confirmed by the DON, the consultant’s recommendations were not updated in the clinical record, resulting in the resident continuing on the original wound vac settings contrary to the consultant’s recommendation.
Three severely cognitively impaired residents, all dependent on staff and diagnosed with dementia, were left in a day room where the temperature exceeded the facility's policy, reaching 83.9°F. Observations showed one resident with a flushed face and another with a clammy appearance. Staff confirmed that the room's air conditioning unit was not functioning, and the issue had been identified in a recent audit.
Essential equipment, specifically PTAC units in resident rooms, were found with filters covered in thick debris. The Maintenance Director confirmed filters had not been cleaned as required by manufacturer instructions, believing they only needed cleaning twice a year, and had not performed this maintenance since starting employment.
A resident with a physician's order for a tooth extraction did not have an appointment scheduled with an oral surgeon, resulting in the procedure not being completed. The resident continued to experience tooth sensitivity, and the DON confirmed that the required dental appointment was never made.
A resident with diabetes and no natural teeth was documented as receiving denture care, despite not having dentures due to their loss. Nurse aide documentation inconsistently recorded denture care as provided or refused, and the DON confirmed the records did not accurately reflect the resident's status.
A resident who required two-person assistance for bed mobility was cared for by a single nurse aide who did not review the care plan or Kardex prior to providing care. As a result, the resident fell from bed and sustained multiple fractures and a scalp laceration. The aide had previously received education on abuse/neglect policies and care plan review, but failed to follow established protocols.
A resident who required two staff for bed mobility, due to recent hip surgery and confusion, was assisted by only one nurse aide who had not reviewed the care plan. During a bed change, the resident fell out of bed, sustaining facial and neck fractures and a scalp laceration. The DON confirmed the aide did not follow the care plan, leading to the fall and injuries.
The facility did not properly store or monitor food in resident refrigerators, with multiple food items kept past their use-by dates and refrigerator temperatures exceeding safe limits. Staff failed to document temperatures as required, and the dietary department did not ensure timely removal of expired food, as confirmed by interviews and observations.
The facility failed to maintain its cooking facilities according to NFPA 101 standards, as it lacked documentation for the semi-annual testing and maintenance of the kitchen fire suppression system. This deficiency, affecting one of nine smoke compartments, was confirmed during an interview with the DON and Maintenance Director.
The facility failed to maintain the automatic sprinkler system in one location, affecting one of nine smoke compartments. Two sprinkler heads above the dryers in the Laundry Room were found dirty and dusty, potentially affecting their activation. This deficiency was confirmed by the DON and Maintenance Director.
Cedarwood Rehabilitation and Healthcare Center's Emergency Preparedness Plan was found deficient due to missing updated names and contact information for staff and resident physicians. This was confirmed by the facility's leadership during a survey, indicating a lapse in maintaining essential documentation for emergency situations.
A facility failed to follow physician's orders for a resident with renal failure requiring dialysis. The resident was prescribed 210 mg of Auryxia five times a day, but was only receiving it three times daily. This was confirmed by the DON, indicating a failure in medication administration as per the physician's orders.
The facility failed to follow physician's orders for enteral feedings for three residents. One resident did not have the amount of Jevity 1.5 documented, another had improper verification of gastric residual volume and lacked weight monitoring, and a third had residual volume checks documented incorrectly. The DON confirmed these deficiencies.
The facility failed to serve palatable food, as residents reported receiving cold meals. Observations during a lunch service showed that food temperatures were below the required 130 degrees Fahrenheit, with ground sausage, noodles, and broccoli served at 120 degrees Fahrenheit. The Dietary Manager confirmed the need for proper food temperatures.
The facility failed to store and prepare food according to professional standards, with open and undated food items found in the resident refrigerator and improper dishwashing practices observed. The dishwasher did not reach the required sanitization temperature, and a dietary aide did not wash hands between handling dirty and clean dishes, as confirmed by staff interviews.
A resident, who required a two-person assist for transfers due to arthritis and a knee arthroplasty, was improperly transferred by a nurse aide alone, resulting in shoulder pain. Despite prior education on care plans, the aide did not verify the transfer status, leading to neglect as per facility policy.
The facility failed to provide written notification to the responsible parties and Ombudsman for two residents transferred to the hospital. One resident, cognitively intact, was sent for evaluation after lab results, while another, cognitively impaired, was transferred due to being diaphoretic and hard to arouse. In both cases, there was no documented evidence of written notice, confirmed by the DON.
The facility failed to notify two residents or their representatives about the bed-hold policy during hospital transfers. One resident, cognitively intact, was sent to the hospital for evaluation, while another, cognitively impaired, was transferred due to a medical condition. The DON confirmed the lack of documentation for these notifications.
A facility failed to create a comprehensive care plan for a resident's use of an anti-coagulant medication. Although the resident was receiving Eliquis as prescribed, there was no documented care plan addressing its use. The DON confirmed the omission, acknowledging the need for an individualized plan.
A facility failed to update a resident's care plan after a PICC line was removed, as confirmed by the DON. The resident, who was cognitively intact and required substantial assistance, initially had a PICC line for antibiotic administration. Physician's orders later instructed for the PICC line removal, which was observed to be completed, but the care plan was not updated to reflect this change.
A resident received an incorrect dosage of Lexapro due to a failure to clarify a confusing physician's order. The order indicated 10 mg but instructed to give two tablets for a total of 15 mg. The resident, who was cognitively impaired, received 15 mg on two consecutive days. An LPN acknowledged the confusion, and the DON confirmed the need for clarification.
Two residents experienced inadequate supervision and assistance during transfers. One resident was transferred using a mechanical lift without engaging the brakes, contrary to policy. Another resident, requiring a two-person assist, was transferred by a single aide, resulting in shoulder pain. Both incidents highlight lapses in following established care protocols.
The facility failed to discard expired insulin pens in two medication carts, as required by policy and manufacturer's instructions. A Lantus pen for a resident on the third floor and a Lispro pen for another resident on the second floor were found beyond their 28-day expiration period. This was confirmed by nursing staff and the DON.
The facility did not follow its planned menu, as residents reported not always receiving the meals listed. On a specific day, a lemon brownie was supposed to be served for lunch, but a blonde brownie was provided instead. The Dietary Manager confirmed the substitution was due to the absence of a recipe for the lemon brownie.
The facility's QAPI committee failed to address recurring deficiencies, including issues with care plans, quality of care, professional standards, accident hazards, and food service. Despite plans of correction involving audits and committee reviews, compliance was not maintained.
The facility failed to maintain comfortable temperatures in the fourth floor dining room, with temperatures observed between 60 and 70 degrees Fahrenheit. The Maintenance Director noted that closed doors prevented heat circulation, and the HVAC company identified open dampers allowing cold air inside. Once addressed, temperatures returned to normal.
A facility failed to notify a resident's family about a new order for a bladder/renal ultrasound, despite the resident's cognitive impairment and dementia diagnosis. The family was unaware of the order and expressed a desire to be informed about the results. The deficiency was confirmed by the DON, who acknowledged the lack of documentation regarding the notification.
A facility failed to maintain a clean environment for a resident with coronary artery disease, heart failure, and asthma. A fan, belonging to the facility, was observed blowing directly on the resident with a significant amount of dirt and debris on its blade cover. This was confirmed by staff, including the Housekeeping Aide, Infection Preventionist, Housekeeping Manager, and DON, who all acknowledged that the fan should have been clean but was not.
A facility failed to maintain a resident's ability to perform ADLs and ambulate due to the absence of a restorative nursing program. Despite recommendations following therapy sessions, no program was developed or implemented, leading to a decline in the resident's functional abilities.
A resident, who was cognitively intact and had a fracture, anxiety, and depression, experienced a fall during a transfer due to a nurse aide not following the care plan. The aide transferred the resident without the required sit-to-stand lift and assistance of two staff members, based on a previous comment by an LPN, leading to the resident being lowered to the floor.
A facility failed to obtain weekly weights for a resident with significant weight loss, as recommended by the dietician. The resident, who was cognitively impaired and diagnosed with protein calorie malnutrition, required substantial assistance with care needs. Despite the dietician's recommendation for weekly weight monitoring to guide nutritional interventions, no evidence was found that these weights were obtained or monitored. The DON confirmed the absence of physician's orders for the weights, leading to this deficiency.
A facility failed to obtain laboratory specimens as ordered for a resident with multiple health issues, including pulmonary fibrosis and respiratory failure. Despite physician orders for bloodwork, the resident refused the tests on multiple occasions, and there was no documented evidence that the bloodwork was attempted or obtained on the final scheduled date. The DON confirmed the lack of documentation.
A facility failed to follow its planned menu, serving a resident a meal that did not match the advertised menu items, without notifying the resident of the changes. The Dietary Manager confirmed the discrepancy and acknowledged that residents were not informed of the menu changes, which is against the facility's policy.
The facility failed to serve food at appropriate temperatures, as observed during a test tray evaluation. The food cart left the kitchen and arrived on the second floor, with the last resident tray delivered and tested. The temperatures of the food items, including casserole, carrots, coffee, milk, and lemonade, did not meet the facility's policy standards for safe food handling. The Dietary Manager confirmed the deficiency and noted the lack of hot plates to maintain food warmth.
The facility did not ensure dietary staff wore appropriate hair coverings, as required by policy. Observations revealed the Dietary Manager and a dietary worker handling food with uncovered hair and sideburns. The Dietary Manager confirmed the failure to comply with the hair restraint policy.
A facility failed to clarify a physician's order for a resident with peripheral vascular disease, resulting in a deficiency. The order required treatment of the resident's right upper thigh every shift, but records showed it was only done daily at 7:00 a.m. The DON confirmed the order was not clarified to reflect the correct frequency, leading to a failure in meeting professional standards of quality.
A resident admitted with frequent falls and congestive heart failure did not receive prescribed Lasix and was not weighed daily as ordered. The resident's weight increased by 1 pound, but the physician was not notified. The DON confirmed these lapses, citing atypical order documentation as the cause.
A facility failed to obtain lab specimens as ordered for a resident admitted after hospitalization for falls and congestive heart failure. The lab order was missed by the admitting nurse and the reviewing nurse because it was in the narrative of the discharge summary, not in the discharge orders. The DON confirmed the oversight.
Two residents in the facility did not receive their insulin doses timely, as required by the facility's policy. One resident, who was cognitively intact and had diabetes, received Basaglar insulin late on multiple occasions and missed doses due to pharmacy unavailability. Another resident received Glargine insulin later than scheduled on several occasions. The DON confirmed these deficiencies.
A resident experiencing chest discomfort repeatedly requested to see a nurse, but an LPN failed to assess her or notify an RN. The resident was not assessed until much later, when an RN was informed and sent her to the hospital.
Failure to Thoroughly Investigate Resident Fall and Involve All Witnesses
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of a resident fall to rule out abuse or neglect. Facility policy required the nurse supervisor/charge nurse and department director or supervisor to promptly initiate and document an investigation of any accident or incident, including circumstances, witness names and accounts, and other pertinent data, with review by the safety committee. Resident 4 had moderate cognitive impairment, used a wheelchair, and had diagnoses including difficulty walking and generalized muscle weakness. On March 21, 2026, nursing documentation indicated the resident sustained a fall in the hallway, reported hitting his head, complained of severe left shoulder pain, and had a hematoma to the back of the head; the family requested transfer to the emergency department for evaluation. Multiple staff interviews revealed that dietary staff, not nursing staff, first encountered the resident on the floor and physically assisted him before a nurse assessed him, but this information was not fully captured in the facility’s investigation. Nurse Aide 1 and Nurse Aide 2 reported that kitchen/dietary staff had picked the resident up off the floor, and Nurse Aide 3 stated she was told by a kitchen staff member that a resident was on the floor; when she arrived, the resident was already in a rolling desk chair, and she later assisted in transferring him to his wheelchair and submitted a witness statement. Dietary Aide 5 and Dietary Aide 6 each confirmed that they found the resident on the floor, could not locate a nurse, and together lifted him from the floor to a desk chair, with both indicating they completed witness statements. Registered Nurse 4, who was on another floor at the time of the fall, later assessed the resident in his wheelchair, noted he was guarding his arm, crying out in pain, and had hit his head, and sent him to the emergency room. Despite these accounts, the facility’s written investigation of the unwitnessed fall included only witness statements from Nurse Aide 2 and LPN 7 and did not contain statements from the dietary aides who actually assisted the resident from the floor. Nurse Aide 2’s statement described finding the resident already in a wheeled desk chair and transferring him to his wheelchair, while LPN 7’s statement focused on environmental conditions and resident behaviors around the time of the incident and acknowledged she was on break when the fall occurred, returning after RN 4 was already assessing the resident. An orthopedic consultation later documented that the resident had a left proximal humerus fracture after a fall on cement. The Director of Nursing confirmed she did not obtain witness statements from dietary staff because she did not believe they would have assisted the resident in that way and also acknowledged she did not investigate the lack of RN assessment prior to the resident being moved to a rolling desk chair, despite the administrator’s statement that all staff were trained to report resident changes in condition to a nurse.
Failure to Implement Wound Consultant’s Recommendation for Wound Vac Settings
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that wound consultant recommendations were reviewed with and incorporated into the attending physician’s orders for a resident. The resident’s annual MDS assessment dated February 24, 2026, documented that the resident was cognitively intact and had a stage 4 pressure ulcer on the right hip. Physician’s orders dated March 10, 2026, directed staff to clean the right hip wound and surrounding tissue with soap and warm water, rinse with saline, and apply a wound vac, ensuring black foam was placed into the tunneling, with dressing changes scheduled for Monday, Wednesday, and Friday, and suction set at 120 mmHg. A wound consultant note dated March 20, 2026, documented that the same resident’s stage 4 right hip pressure ulcer required a change in wound vac suction from 120 mmHg to 150 mmHg. Review of the resident’s March 2026 Treatment Administration Record showed that, as of March 31, 2026, the recommended change in wound vac suction had not been initiated. In an interview on March 31, 2026, at 12:25 p.m., the Director of Nursing confirmed that the wound care recommendations made by the wound care clinic on March 20, 2026, had not been updated in the resident’s clinical record as of that date, resulting in the failure to meet professional standards of nursing services as required by state regulations.
Failure to Maintain Safe Room Temperatures for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for three residents who were in a day room where the temperature exceeded the facility's policy range. The facility's policy, last reviewed on January 30, 2024, required temperatures to be maintained between 71°F and 81°F. However, on June 26, 2025, the fourth floor day room was observed to have a temperature of 83.9°F. Three residents, all of whom were severely cognitively impaired, dependent on staff for care, and diagnosed with dementia, were present in the room during this time. Observations noted that one resident's face appeared clammy and another's face was flushed and pink after being in the overheated room. Staff interviews revealed that an audit of all PTAC units had been conducted two days prior, identifying multiple non-functioning units, including the one in the affected day room. The Maintenance Director confirmed the malfunction, and the Nursing Home Administrator acknowledged that common areas should be kept within safe temperature ranges. The deficiency was cited under federal and state regulations for failing to provide reasonable accommodation of resident needs and preferences, specifically regarding environmental temperature control.
Plan Of Correction
Plan of Correction: 1. Residents 7, 8, & 9 who were in 4th floor dayroom when temperature was identified above 81 degrees Fahrenheit was redirected to climate-controlled area on unit immediately. 2. New window air conditioner unit was installed to maintain a safe temperature of 71 degrees Fahrenheit to 81 degrees Fahrenheit within the 4th floor dayroom. Corrective actions were put into place to ensure the deficient practice does not reoccur. 3. The administrator re-educated the Maintenance Director on the Facility Policy "Homelike Environment," ensuring that the facility will maintain comfortable temperatures between 71 degrees F and 81 degrees F. 4. A scheduled preventative maintenance program was put into place requiring daily temperature checks to be completed in the 4th floor dayroom for two weeks. After that, audits will be reviewed monthly for the next three months, and then randomly thereafter, with the results of these audits brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Allegation of compliance 7/14/25 I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.
Failure to Maintain PTAC Filters in Safe Condition
Penalty
Summary
The facility failed to ensure that essential equipment, specifically Packaged Terminal Air Conditioner (PTAC) units in resident rooms, were maintained in safe operating condition. Observations in two separate resident rooms revealed that the PTAC filters were covered with a thick, gray-brown layer of removable debris. The Maintenance Director confirmed during interviews that the filters needed cleaning and stated his belief that filters should be cleaned approximately every six months. He also reported that since starting employment in January 2025, he had not cleaned any filters as part of routine maintenance and believed the last cleaning occurred in October or November 2024. Manufacturer instructions for the PTAC units require filter cleaning every two weeks or more often if necessary.
Failure to Schedule Dental Appointment for Tooth Extraction
Penalty
Summary
The facility failed to ensure that a dental appointment was scheduled for a resident who required a tooth extraction. According to facility policy, routine and emergency dental care, including follow-up appointments, must be provided. A quarterly MDS assessment indicated that the resident was cognitively intact, required staff supervision, and had her own natural teeth. A physician's order directed that the resident see an oral surgeon for a tooth extraction, but as of the date of review, there was no documented evidence that the appointment had been made or that the procedure had occurred. The resident reported ongoing tooth sensitivity and confirmed that the extraction had not taken place. The DON confirmed that the necessary appointment was never scheduled.
Incomplete and Inaccurate Clinical Record Documentation for Denture Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident. A quarterly MDS assessment indicated that the resident was able to communicate and had a diagnosis of diabetes. A dental summary documented the insertion of lower complete dentures and that care instructions were provided. However, during an interview and observation, the resident was found to have no natural teeth and was not wearing dentures, stating that his dentures were broken and unavailable. Review of nurse aide documentation over several months showed inconsistent entries regarding denture care, with some shifts marked as 'not applicable/refused' and others as 'yes.' A nurse aide clarified that she marked 'refused' or 'not applicable' because the resident did not have dentures to care for, not because the resident refused care. The DON confirmed that the documentation was inaccurate, as the resident's dentures were lost, and the records did not reflect the actual situation.
Failure to Follow Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in harm. A resident who had recently been admitted following a hip fracture and surgery required extensive assistance from two staff members for bed mobility, as documented in the care plan and Kardex. Despite this, a nurse aide provided care alone and attempted to roll the resident in bed for a complete bed change. During this process, the resident rolled out of bed and fell to the floor, sustaining a nasal bone fracture, an acute nondisplaced fracture of the odontoid process, and a scalp laceration requiring sutures. The nurse aide involved had received education on the facility's abuse and neglect policy, as well as on reviewing the resident's Kardex prior to providing care. However, the aide admitted to not reviewing the Kardex before assisting the resident and was unaware of the requirement for two-person assistance. The Director of Nursing confirmed that the aide's failure to follow the care plan directly resulted in the resident's fall and injuries.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when a resident, who had recently undergone surgery for a hip fracture and required extensive assistance from two staff members for bed mobility, was left under the care of only one nurse aide. The resident's care plan, which specified the need for two staff during bed mobility, was not followed. The nurse aide, without reviewing the resident's Kardex or care plan, attempted to perform a complete bed change alone. During this process, the resident rolled out of bed and fell to the floor. As a result of the fall, the resident sustained multiple injuries, including a nasal bone fracture, an acute nondisplaced fracture through the base of the odontoid process, and a left frontal scalp laceration requiring sutures. The nurse aide later admitted to not reviewing the care plan prior to providing care and was unaware of the two-person assistance requirement. The Director of Nursing confirmed that the failure to follow the resident's care plan for bed mobility led to the resident's fall and subsequent injuries.
Failure to Store Food Safely and Maintain Refrigerator Temperatures
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in three resident refrigerators. Policy required all foods stored in refrigerators or freezers to be labeled with the resident's name and use-by dates, and to be kept at or below 41°F. Observations revealed multiple food items, such as fried chicken, barbequed ham, salad, pizza, and a cheesesteak sandwich, were stored past their labeled use-by dates, with some items remaining in the refrigerators for over a week. Additionally, facility-prepared soup was found with dates exceeding the three-day limit. Staff interviews confirmed that these foods should have been discarded within three days, as per policy. Temperature logs for the refrigerators were not maintained as required, with no documentation since the morning of March 3, 2025. Observed refrigerator temperatures ranged from 48°F to 50°F, exceeding the maximum allowed by policy. Staff interviews confirmed that the dietary department was responsible for cleaning out the refrigerators and recording temperatures twice daily, but these tasks were not completed. Notices on the refrigerators reiterated the policy, but compliance was not observed. The Dietary Director acknowledged the deficiencies in food storage, temperature control, and documentation.
Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically regarding the kitchen fire suppression system. During an observation and document review on January 14, 2025, it was found that the facility did not have documentation for the required semi-annual testing and maintenance of the kitchen fire suppression system, which was due between January and June 2024. This deficiency was confirmed during an interview with the Director of Nursing and the Maintenance Director on the same day, affecting one of the nine smoke compartments in the facility.
Plan Of Correction
1. The facility will obtain documentation for the semi-annual testing/maintenance of the kitchen fire suppression system. 2. Maintenance director or designee will verify that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. 3. Nursing home administrator or designee will re-educate the maintenance director of completing semi-annual testing/maintenance of the kitchen fire suppression timely. 4. Maintenance director or designee will audit that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of Compliance will be 2/18/2025.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in one location, specifically affecting one of nine smoke compartments. During an observation on January 14, 2025, at 11:45 a.m., two sprinkler heads located above the dryers in the Laundry Room were found to be dirty and dusty. The accumulation of dirt and dust on these sprinkler heads could potentially affect their activation in the event of a fire. This deficiency was confirmed during an interview with the Director of Nursing and the Maintenance Director on the same day at 2:30 p.m. The failure to maintain the cleanliness of the sprinkler heads indicates a lapse in the regular inspection and maintenance protocols as required by NFPA 25, which governs the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
1. Sprinkler heads identified have been cleaned. 2. Maintenance director or designee will conduct a facility audit to verify that sprinkler heads are free from dust. 3. Nursing home administrator or designee will re-educate the maintenance director on properly maintaining the sprinkler heads in the facility verifying they are free from dust. 4. Maintenance director or designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that the sprinkler heads are free from dust. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
Cedarwood Rehabilitation and Healthcare Center was found to have deficiencies in its Emergency Preparedness (EP) Plan during a survey conducted on January 14, 2025. The facility failed to include updated and accurate names and contact information for its staff and resident physicians, which is a requirement under 42 CFR 483.73. This deficiency was identified through a review of the facility's EP Plan and confirmed during interviews with the Director of Nursing and the Maintenance Director. The survey revealed that the EP Plan did not meet the necessary standards as it lacked essential contact details, which are crucial for effective communication during emergencies. The absence of this information was confirmed by the facility's leadership, indicating a lapse in maintaining the required documentation for emergency preparedness. This oversight has the potential for minimal harm, as it could impede timely communication and coordination in emergency situations.
Plan Of Correction
1. The facility EP plan has been updated to accurately reflect the proper staff and physician contact information. 2. Maintenance director or designee will verify it is updated if information changes. 3. Nursing home administrator or designee will re-educate the maintenance director on accurately and timely updating the EP plan as contact information changes. 4. Maintenance director or designee will audit the EP plan monthly for the next three months to verify contact information is accurate. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for one resident. Resident 99, who is cognitively intact and requires assistance for daily care needs, has a diagnosis of renal failure necessitating dialysis. The physician's orders from the dialysis center specified that the resident should receive 210 mg of Auryxia five times a day with meals and snacks. However, a review of the Medication Administration Record for January 2025 revealed that the resident was only receiving the medication three times per day. This discrepancy was confirmed in an interview with the Director of Nursing, who acknowledged that the resident was not receiving the medication as prescribed.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that physician's orders for enteral feedings were followed for three residents. Resident 16, who was cognitively intact and required maximum assistance, had an order to receive Jevity 1.5 at a rate of 60 ml/hour. However, there was no documentation in the Medication Administration Record (MAR) for January 2025 indicating the amount administered each shift. An LPN admitted to not knowing how to clear the machine to ensure the correct amount was given. The Director of Nursing confirmed the lack of documentation. Resident 54, who was severely cognitively impaired, had orders to check gastric residual volume (GRV) before medication and feeding. An LPN failed to properly verify the GRV by not using the plunger to withdraw stomach contents. Additionally, there was no documented evidence of a reweigh to confirm an 11.4-pound weight loss or weekly weights as recommended. Resident 67, who was cognitively impaired, had orders to check residual volume before each feeding and medication administration, but it was only documented as verified every shift. The Director of Nursing confirmed these deficiencies.
Failure to Serve Palatable Food
Penalty
Summary
The facility failed to serve food that was palatable, as evidenced by observations and resident interviews. A review of the facility's policy on food preparation and service, dated January 25, 2024, indicated that hot foods should be served above 130 degrees Fahrenheit. However, during an interview with a group of residents, it was revealed that food delivered to their rooms was served cold. Observations during the lunch meal service showed that a test tray, which included ground sausage and noodles, broccoli, a rootbeer float dessert cup, milk, and coffee, was served to residents. The test tray's temperature readings showed that the ground sausage and noodles and broccoli were at 120 degrees Fahrenheit, below the required temperature, making them cool and unappetizing. The Dietary Manager confirmed that foods should be served at proper and palatable temperatures.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and preparation. Observations in the kitchen revealed a box of frozen egg patties that were open to air, which was confirmed by the Dietary Manager. Additionally, the resident refrigerator on the second floor contained multiple opened and undated containers of milk and iced tea, some of which were not labeled with a resident's name and had expired sell-by dates. Interviews with a Registered Nurse and the Dietary Manager confirmed that these items should have been labeled, dated, and discarded after expiration. Further deficiencies were noted in the dishwashing process. The dishwasher was not reaching the required hot water final rinse temperature of 180 degrees Fahrenheit because the hot water booster was not turned on. Dietary Aide 11, who was handling dirty dishes, moved to the clean side and began stacking clean dishes without washing his hands, which was against expected hygiene practices. The Dietary Manager confirmed that the dishwasher could use chemicals if necessary, but the hot water booster should have been on to ensure proper sanitization. The Director of Nursing also confirmed that dietary staff were expected to wash their hands between handling dirty and clean tasks.
Neglect in Resident Transfer Procedure
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by the incident involving Resident 95. The resident, who was cognitively intact and required maximum assistance for transfers due to conditions including arthritis and a recent total knee arthroplasty, was transferred improperly by a nurse aide. The resident's care plan specified a two-person physical assist for transfers, but Nurse Aide 1 transferred the resident alone, resulting in pain to the resident's right shoulder. This incident was reported by the resident to the physical therapy department, which then initiated an investigation. The investigation revealed that Nurse Aide 1 did not verify the transfer status before proceeding with the transfer, which was against the facility's policy on abuse, neglect, exploitation, and misappropriation. Despite having been educated on following care plans, Nurse Aide 1 failed to adhere to the required protocol, leading to the resident's injury. The Director of Nursing confirmed the resident's transfer requirements and the nurse aide's failure to comply, which resulted in the resident experiencing pain.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the resident, responsible party, and Ombudsman regarding the reason for hospitalization for two residents. Resident 19, who was cognitively intact and required assistance for daily care needs, was sent to the hospital for evaluation after lab results were reviewed by a certified registered nurse practitioner. Although the resident's responsible party was notified and agreed to the transfer, there was no documented evidence of a written notice being provided to the responsible party or the Ombudsman. Similarly, Resident 67, who was cognitively impaired and dependent on staff for daily care needs, was transferred to the hospital after being found diaphoretic and hard to arouse. The family requested the transfer, and the physician agreed. However, there was no documented evidence that a written notice of the transfer was provided to the resident's responsible party or the Ombudsman. The Director of Nursing confirmed that the facility did not provide the required written notices for both residents.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify appropriate parties about the bed-hold policy during hospital transfers for two residents. The facility's policy, dated January 25, 2024, mandates that residents and/or their representatives be informed in writing of the bed-hold policy. However, for Resident 19, who was cognitively intact and required staff assistance for daily care, there was no documented evidence of such notification when the resident was transferred to the hospital on June 6, 2024, following a CRNP's order for evaluation. Similarly, Resident 67, who was cognitively impaired and dependent on staff, was transferred to the hospital on September 24, 2024, after being found diaphoretic and hard to arouse. The family requested the transfer, and the physician agreed. Again, there was no documented evidence that the resident or their responsible party was informed of the bed-hold policy. The Director of Nursing confirmed the lack of documentation for both residents, acknowledging that notifications should have been issued.
Failure to Develop Individualized Care Plan for Anti-Coagulant Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident regarding the use of an anti-coagulant medication. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and was prescribed Eliquis, an anti-coagulant, to be taken every 12 hours. Despite the medication being administered as per the physician's orders, there was no documented evidence of a care plan addressing the specific use of the anti-coagulant for this resident. An interview with the Director of Nursing confirmed the absence of an individualized care plan for the resident's anti-coagulant use, acknowledging that it should have been included.
Failure to Update Care Plan for Discontinued PICC Line
Penalty
Summary
The facility failed to update the care plan for Resident 91 to reflect changes in care needs. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact, required substantial assistance, and was receiving an intravenous antibiotic through a peripherally inserted central catheter (PICC) in her right upper arm. However, physician's orders dated December 10, 2024, instructed for the PICC line to be removed, and observations on January 7, 2025, confirmed that the PICC line was no longer present. Despite this, the care plan was not updated to reflect the discontinuation of the PICC line, as confirmed by the Director of Nursing during an interview on January 10, 2025.
Failure to Clarify Physician's Order Leads to Medication Error
Penalty
Summary
The facility failed to clarify a physician's order for a resident, leading to a medication administration error. The resident, who was cognitively impaired but able to understand and be understood, had a physician's order dated January 8, 2024, for Lexapro, a medication used to treat depression and anxiety disorders. The order was confusing as it stated to administer 10 mg of Lexapro but also instructed to give two tablets for a total of 15 mg. This discrepancy was not clarified by the nursing staff. As a result, the resident received 15 mg of Lexapro on January 8 and 9, 2024, as documented in the Medication Administration Record. An LPN observed administering one and one-half tablets of Lexapro, which was consistent with the pharmacy's supply of 10 mg tablets. The LPN acknowledged the confusion in the order and the need for clarification. The Director of Nursing confirmed that the order should have been clarified to prevent the administration error.
Failure to Ensure Adequate Supervision and Assistance During Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for two residents. For Resident 79, who was cognitively intact and required extensive assistance with transfers, the staff did not engage the brakes on the mechanical lift during a transfer from a wheelchair to a bed. This was against the facility's policy and the manufacturer's instructions for the lift, which required brakes to be engaged during lifting and lowering. Both Nurse Aide 3 and Nurse Aide 4 confirmed the oversight, and the Assistant Director of Nursing acknowledged that the brakes should have been engaged. For Resident 95, who was also cognitively intact and required maximum assistance for transfers, a nursing note indicated new shoulder pain after a transfer. An investigation revealed that Nurse Aide 1 transferred the resident alone, contrary to the care plan that required a two-person assist. The resident reported that the aide twisted her arm during the transfer, causing pain. The Director of Nursing confirmed that the transfer was conducted improperly, and documentation showed that Nurse Aide 1 had previously been educated on following care plans.
Failure to Discard Expired Insulin Pens
Penalty
Summary
The facility failed to properly discard expired insulin pens in two of the three medication carts reviewed, specifically on the second and third floor long hall medication carts. According to the facility's policy and the manufacturer's instructions, insulin pens should be discarded 28 days after being opened. However, during observations, it was found that a Lantus insulin pen for Resident 17, which was opened on a previous date, was still in the cart beyond the 28-day period. This was confirmed by an LPN during the observation. Similarly, a Lispro insulin pen for Resident 89 was also found in the second-floor medication cart past the 28-day expiration period. The pen was opened on a previous date and should have been discarded, as confirmed by an RN during the observation. The Director of Nursing also confirmed that insulin pens should be discarded 28 days after being opened and in use, indicating a lapse in adherence to the facility's medication management policies.
Failure to Follow Planned Menu
Penalty
Summary
The facility failed to adhere to their planned menu, as evidenced by a review of facility policies, written menus, and observations, as well as interviews with staff and residents. The facility's policy, dated January 24, 2024, required that menus be written in advance, posted in resident areas, and any deviations recorded on a substitution log. However, during an interview with a group of residents on January 7, 2025, it was revealed that they do not always receive the meals listed on the menu. Specifically, the lunch menu for January 7, 2025, indicated that residents were to receive a lemon brownie, but observations in the kitchen showed a yellow cake prepared instead. During the lunch meal service, a blonde brownie was served instead of the lemon brownie. The Dietary Manager confirmed on January 9, 2025, that the substitution occurred because there was no recipe available for the lemon brownie.
Repeated Deficiencies in Care Plans and Food Service
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. These deficiencies included issues with creating and updating comprehensive care plans, maintaining quality of care, meeting professional standards, and ensuring a safe environment free of accident hazards. Despite developing plans of correction that involved completing audits and reporting results to the QAPI committee, the facility did not achieve ongoing compliance with these regulations. Additionally, the facility was cited for deficiencies related to food service, including not following menus made in advance, failing to provide nutritious and palatable food, and not preparing, storing, and serving food under sanitary conditions. These issues were identified in surveys conducted throughout 2024 and into early 2025, indicating a persistent failure by the QAPI committee to implement effective corrective actions and maintain compliance with the required standards.
Temperature Control Issues in Dining Room
Penalty
Summary
The facility failed to maintain comfortable temperatures in one of its dining rooms, specifically the fourth floor dining room. On January 7, 2025, observations revealed that the temperature was 64 degrees Fahrenheit while five residents were waiting for lunch. Further observations on January 9, 2025, showed temperatures ranging from 60 to 70 degrees Fahrenheit while five people were eating. Interviews with the Maintenance Director indicated that the dining room doors were closed, preventing heat from circulating from the hallways, and that the temperature was outside acceptable parameters. The HVAC company owner noted that dampers were slightly open to the outside, allowing cold air to circulate into the dining room, but once closed, the temperatures returned to normal range.
Failure to Notify Resident's Family of New Physician's Order
Penalty
Summary
The facility failed to notify a resident's representative about a new physician's order, which is a requirement according to the facility's policy on changes in a resident's condition or status. The policy mandates that a nurse must inform the resident's representative of any significant change in the resident's physical, mental, or psychosocial status. In this case, a resident who was cognitively impaired and diagnosed with dementia had a new order for a bladder/renal ultrasound due to sediment in the urine, as noted by the family and reported by the resident. However, there was no documented evidence that the resident's family was informed of this new order. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the notification to the resident's family. The family had expressed their desire to be informed about the ultrasound results, indicating that they were not aware of the new order. This oversight was identified during a review of facility policies, clinical records, and staff interviews, highlighting a failure in communication and adherence to the facility's notification policy.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident 6, who was cognitively intact and had diagnoses including coronary artery disease, heart failure, and asthma. During an observation, it was noted that a stand-up fan, belonging to the facility, was blowing directly on the resident while having a significant amount of visible dirt and debris accumulated on its blade cover. This condition was confirmed by both the Housekeeping Aide and the Infection Preventionist, who acknowledged that the fan should have been clean but was not. Further interviews with the Housekeeping Manager and the Director of Nursing confirmed that the fan cover should have been cleaned with a damp rag during room cleaning, but it was not. The deficiency was identified under the resident's rights to a safe, clean, comfortable, and homelike environment, as outlined in the facility's policy on cleaning and disinfecting. The failure to maintain cleanliness was a violation of the resident's rights and the administrator's responsibility as per the relevant Pennsylvania Code.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to maintain or improve their abilities to perform activities of daily living (ADLs) and ambulate. The resident, who was cognitively impaired and had multiple diagnoses including pulmonary fibrosis, respiratory failure, asthma, and rheumatoid arthritis, experienced a decline in functional mobility. Initially, the resident was able to perform bed mobility tasks and functional transfers with minimal assistance and could ambulate 60 feet with a walker. However, after being discharged from physical therapy, no program was implemented to maintain the resident's functional mobility. Subsequent therapy sessions revealed a further decline in the resident's abilities, requiring moderate to maximum assistance for tasks previously performed with less help. Despite recommendations for a restorative nursing program to maintain the resident's current level of performance and prevent further decline, there was no documented evidence that such a program was developed or implemented. Interviews with facility staff, including the Director of Nursing, confirmed the absence of restorative nursing programs to prevent decline and maintain the resident's ability to perform ADLs and ambulation.
Failure to Follow Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that safe transfer techniques were used in accordance with the care plan for a resident, resulting in a fall. The resident, who was cognitively intact and had a diagnosis of a fracture, anxiety, and depression, was supposed to be transferred using a stand-up lift with a medium sling and the assistance of two staff members. However, during a transfer from a chair to a bed, the resident lost balance and was lowered to the floor by a nurse aide onto her left knee, although no injuries were reported. The incident occurred because the nurse aide did not follow the resident's care plan. The aide reported that he transferred the resident without the sit-to-stand lift, as he was under the impression that it was unsafe based on a previous comment by an LPN. The aide did not verify the care plan before proceeding with the transfer. The Director of Nursing confirmed that the care plan was not followed, which led to the deficiency being cited as past non-compliance.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to ensure that weekly weights were obtained for a resident who experienced significant weight loss, as recommended by the dietician. The resident, who was cognitively impaired and required substantial assistance with care needs, had a diagnosis of protein calorie malnutrition and had been experiencing significant weight loss. The dietician had noted the resident's weight loss and recommended weekly weight monitoring to assess the need for further nutritional interventions. However, there was no documented evidence that these weekly weights were obtained or that the dietician continued to monitor the resident's weight loss and nutritional status. The Director of Nursing confirmed that the dietician did not place physician's orders for the weekly weights, resulting in the failure to monitor the resident's weight as recommended. This oversight was identified during a review of the resident's clinical records for October and November, which showed no documentation of the recommended weekly weights. The deficiency was cited under 28 Pa. Code 211.12(d)(3)(5) Nursing Services, indicating a lapse in the facility's responsibility to provide adequate nursing services to maintain the resident's health.
Failure to Obtain Ordered Laboratory Specimens
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered for a resident. The resident, who was cognitively impaired and required substantial assistance with care needs, had significant weight loss and multiple diagnoses, including pulmonary fibrosis, respiratory failure, asthma, rheumatoid arthritis, and protein calorie malnutrition. A physician's order dated October 7, 2024, required bloodwork to be completed on the same day, including tests for calcium level, sed rate, CHEM 4, albumin, AST, ALT, Creatinine, and a CBC with auto diff. Despite the physician's order, the resident refused the annual labs on October 8, 2024, and staff planned to attempt again on October 9, 2024. The medical director and resident representative were informed of the refusal. On October 9, 2024, the resident again refused the labs, and staff planned another attempt on October 10, 2024. However, there was no documented evidence that the bloodwork was attempted or obtained on October 10, 2024. The Director of Nursing confirmed the lack of documentation for the ordered bloodwork.
Failure to Follow Planned Menu and Notify Residents of Changes
Penalty
Summary
The facility failed to adhere to its planned menu as required by its policy, which mandates that menus be served as written unless changes are made due to preference, unavailability, or special meals, with deviations recorded. On December 10, 2024, the lunch menu was supposed to include chunky cheeseburger casserole, glazed sweet carrots, garlic bread, and lemon brownies. However, observations revealed that a resident received a meal with a half of a hot dog bun with butter instead of garlic bread, and a chocolate brownie instead of a lemon brownie. The resident expressed that the menu often does not match what is served and had documented the discrepancies on her menu. The Dietary Manager confirmed that residents were not informed of the menu changes and acknowledged that the advertised items, garlic bread and lemon brownies, were not provided. The manager, who is new to the facility but experienced in dietary services, stated that she is working on improving the dietary experience. This failure to follow the planned menu and notify residents of changes is a violation of the facility's dietary services policy.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food safety by not ensuring that food was served at appropriate temperatures. During a test tray observation conducted on December 10, 2024, it was noted that the food cart left the kitchen at 12:49 p.m. and arrived on the second floor at 12:50 p.m. The last resident tray was delivered, and the test tray was tested at 1:02 p.m. The test tray included chunky cheeseburger casserole, glazed sweet carrots, bread, brownies, milk, pink lemonade, and coffee. The temperatures recorded were 129.7 degrees Fahrenheit for the casserole, 116.1 degrees Fahrenheit for the carrots, 140 degrees Fahrenheit for the coffee, 49.1 degrees Fahrenheit for the milk, and 60 degrees Fahrenheit for the pink lemonade. These temperatures did not meet the facility's policy standards, which require hot foods to be at least 135 degrees Fahrenheit and cold foods to be at 41 degrees Fahrenheit or lower. The Dietary Manager confirmed during an interview that the food should have been served at safe and appropriate temperatures in compliance with safe food handling practices. The manager acknowledged that the facility currently lacks hot plates to maintain food warmth and expressed a future plan to serve meals from steamers in the dining areas to ensure hot food for residents. The deficiency was identified under 28 Pa. Code 211.6(f) Dietary Services, indicating a failure to adhere to the established guidelines for food safety and temperature control.
Failure to Ensure Dietary Staff Wore Appropriate Hair Coverings
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that dietary staff wore appropriate hair coverings. The facility's policy, dated January 25, 2024, mandates that all kitchen employees must wear hair restraints to effectively keep hair properly restrained. However, during observations on December 10, 2024, it was noted that the Dietary Manager was involved in stirring, temping, and plating food with two to three inches of hair at the back of her head and approximately one inch of hair on the side of her face not covered. Additionally, a dietary worker was observed placing desserts and lids onto meal trays with sideburns that were not completely covered. An interview with the Dietary Manager confirmed that both she and the dietary worker should have had their hair completely covered when handling food for residents, which they did not.
Failure to Clarify Physician's Order for Resident Care
Penalty
Summary
The facility failed to clarify a physician's order for a resident, leading to a deficiency in the care provided. The resident, who was cognitively intact and required substantial assistance with personal hygiene, had a diagnosis of peripheral vascular disease. The physician's order, dated January 25, 2024, required the treatment of the resident's right upper thigh to be completed every shift, every day, to address moisture-associated skin damage. However, the treatment administration record for July, August, and September 2024 showed that the treatment was only being completed daily at 7:00 a.m. An interview with the Director of Nursing on September 17, 2024, confirmed that the physician's order was not clarified to reflect the correct frequency of treatment, which should have been every shift. This oversight resulted in the facility not meeting the professional standards of quality as outlined in the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4). The failure to adhere to the physician's order as intended led to a deficiency in the nursing services provided to the resident.
Failure to Follow Admission Orders for Resident
Penalty
Summary
The facility failed to follow admission orders for a resident who was admitted with diagnoses including frequent falls and congestive heart failure. The admission orders required the resident to be weighed daily and for the physician to be notified of a weight gain of 1 to 2 pounds in one day or 5 pounds in one week. Additionally, the resident was to receive 20 mg of Lasix daily. However, the Treatment Administration Record for June 2024 showed that the resident did not receive the prescribed Lasix and was not weighed daily as ordered. The resident's weight was recorded on June 13 and June 14, showing a 1-pound increase, but the physician was not notified. An interview with the Director of Nursing confirmed these lapses, attributing them to the admission orders not being written in the typical fashion, leading to the oversight.
Failure to Obtain Ordered Lab Specimens
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered for a resident. The resident was admitted to the facility after being hospitalized for multiple falls and congestive heart failure. Hospital discharge instructions included orders for repeat lab work to be conducted one to two days after discharge. However, no labs were ordered or obtained during the resident's stay at the facility. An interview with the Director of Nursing revealed that the admitting nurse and the nurse reviewing the admission orders missed the lab order because it was included in the narrative of the discharge summary and not among the discharge orders. The Director of Nursing confirmed that the labs should have been obtained but were not.
Delayed and Missed Insulin Administration
Penalty
Summary
The facility failed to administer insulin timely for two residents and did not provide medications as ordered for one resident. The facility's policy required medications to be administered within one hour of their prescribed time. However, Resident 1, who was cognitively intact and had diabetes, received Basaglar insulin at times significantly later than the scheduled 8:00 a.m. and 8:00 p.m. doses on multiple occasions in April and May 2024. Additionally, Basaglar was not administered at all on May 27 and May 28, 2024, due to unavailability from the pharmacy. Resident 4, also cognitively intact with diabetes, received Glargine insulin later than the scheduled 8:00 p.m. dose on several occasions in April and May 2024. The Director of Nursing confirmed that the insulin was not administered timely according to the facility's policy, and Resident 1 did not receive Basaglar as ordered on specific dates. The report highlights the facility's failure to adhere to its medication administration policy, resulting in delayed or missed insulin doses for the residents involved.
Failure to Timely Assess Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a licensed nurse completed a timely assessment when a change in condition occurred for one resident. The facility's policy required a nurse to make detailed observations and gather relevant information when a change in condition was reported. On the day of the incident, the resident reported chest discomfort and requested to see a nurse multiple times throughout the afternoon. Despite these requests, the resident was not assessed by a nurse until much later in the evening. The resident initially reported her symptoms to a nurse aide, who relayed the information to an LPN. However, the LPN did not assess the resident or notify a registered nurse. The resident continued to express her discomfort and request assistance, but no assessment was conducted until a registered nurse was informed by another nurse aide later in the evening. The registered nurse then assessed the resident and sent her to the hospital for further evaluation.
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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